Suture sleeve patch and methods of delivery within an existing arthroscopic workflow

ABSTRACT

Suture delivered patches adapted for interposition, augmentation or repair devices for use in tendon and ligament repair, including rotator cuff repair, have been developed as well as methods for their delivery using suture guided arthroscopic methods. The repair patches may be provided from suitable biocompatible materials. The patches may be delivered using anchored sutures already in use during a surgical repair including, open, minimally invasive, endoscopic, and arthroscopic repair procedures. Additionally, fixation of the suture delivered repair patch is secured along with the normal suture securing workflow of the one or more sutures used to deliver the patch.

CROSS REFERENCE TO RELATED APPLICATIONS

This application is a continuation of U.S. patent application Ser. No.15/339,782, filed Oct. 31, 2016, titled “SUTURE SLEEVE PATCH AND METHODSOF DELIVERY WITHIN AN EXISTING ARTHROSCOPIC WORKFLOW,” now U.S. PatentApplication Publication No. 2017/0143551, which claims priority to U.S.Provisional Patent Application No. 62/248,346, filed Oct. 30, 2015,titled “SUTURE SLEEVE,” which is herein incorporated by reference in itsentirety.

INCORPORATION BY REFERENCE

All publications and patent applications mentioned in this specificationare herein incorporated by reference to the same extent as if eachindividual publication or patent application was specifically andindividually indicated to be incorporated by reference.

FIELD

Embodiments of the present invention generally relate to devices andmethods for repairing ligaments and tendons, in particular embodimentsfor repair of rotator cuff tendons using arthroscopically deliveredpatches.

BACKGROUND

The rotator cuff is a confluence of tendons that connect the musclesoriginating around the scapula and inserting on the upper humerus. Whenactivated, these muscles raise, lower, and rotate the arm. The rotatorcuff tendons measure about 5 cm in width, on average, and together theyform a cuff that encapsulates the article surface at the top of thehumerus. The acromion (the bone on the top of the shoulder) forms a bonyand ligamentous arch over the rotator cuff and is bordered by theacromioclavicular ligament, the coracoid (the bone in front of theshoulder), and the acromioclavicular joint.

The rotator cuff can be injured by a number of different mechanisms. Forexample, if a person falls and lands on his shoulder, the acromion canstrike the rotator cuff causing injury to the muscles or tendons. Theextent of the injury, which can be either a bruise or tear, depends onthe position of the arm during the fall, the strength and flexibility ofthe muscles and tendons, and the geometry of the undersurface of theacromion.

When the cuff is bruised, bleeding into the tendons may occur, and thetendons can swell, causing the cuff to be compressed, given the relativenarrowness of the space provided for the cuff. This condition maypersist for some months and is typically characterized by weakness andpain, especially when the outstretched arm is raised to the side orrotated. Symptoms are usually self-limited after appropriate treatment.

A torn rotator cuff is a significantly more serious problem. Symptomsare similar, although nighttime pain is often more intense, and theability of the muscle to move the arm is significantly weakened,resulting in limited motion. If the condition does not stabilize overtime with rest and supportive care, surgery is often recommended(especially in cases where the cuff tear is significant, and/or in orderto prevent the development of osteoarthritis). The size of the tear istypically determined using an arthrogram or by MRI.

While the surgical repair has historically been performed as an openprocedure (and more recently as a “mini-open” repair), the majority ofrotator cuff repairs are now repaired fully arthroscopically, with thetendon being reattached directly to the bony insertion on the laterialborer of the humerus. However, when direct reattachment is not possible,for example, because retraction of the muscle has created a largedefect, interposition devices or grafts (including synthetic cuffprostheses) are used to fill the defect. Devices (or grafts) are alsoused as augmentation devices to strengthen a repair to prevent recurrenttears and allow for a more aggressive rehabilitation particularly inyounger patients.

It is estimates that approximately 250,000 rotator cuff repairprocedures are performed each year to alleviate the persistent pain anddiscomfort associated with shoulder injuries, and help patients regainfull range of motion. There is thus a significant need for improved useand integration of devices to aid in or augment healing of a repairwithin an existing surgical workflow. Moreover, there remains a need forthe development of such devices and integration within existing suturerepair workflow.

SUMMARY OF THE DISCLOSURE

A variety of different patch structures adapted for suture delivery aredescribed herein for rotator cuff repair should be useful in thetreatment of patients with torn rotator cuffs readily since the patch isdelivered within the existing surgical workflow and may be used toprovide a variety of different materials to improve healing of thesurgical site.

In general, in one embodiment, a device to promote healing at a suturesurgical repair site includes a patch having an overall shape, aproximal end and a distal end, and a suture conduit along the patchsized to allow passage of a suture and permit relative movement of thepatch along a suture disposed within the suture conduit.

This and other embodiments can include one or more of the followingfeatures. When the patch is positioned to promote healing at thesurgical repair site, a suture can be disposed within the suture conduitand can extend along the patch beyond the proximal end and beyond thedistal end. The suture conduit can be a continuous conduit from theproximal end to the distal end of the patch. The suture conduit can be asegmented conduit having two or more suture guide structures spacedalong the patch to align the suture disposed within the two or moresuture guide structures relative to the proximal end and a distal end ofthe patch. The two or more suture guide structures can be formed usingan element used to assemble the patch. Where the element is a filament,at least a portion of the patch can be assembled by a stitching processusing the filament and the two or more suture guide structures are loopsof filament formed during the stitching process. The element can be afastener having a suture guide formed thereon such that when thefastener is engage with a portion of the patch the suture guide ispositioned to receive and align the suture relative to the proximal endand the distal end of the patch. The suture conduit can be an apertureformed within the patch extending from the proximal end to the distalend. The suture conduit can be an elongate hollow structure insertedinto the patch. The elongate hollow member can be present only whileloading the patch on to the suture or while advancing the patch to thesurgical repair site. The elongate hollow member can be present when thepatch is secured in place in the surgical repair site.

The overall shape of the patch can be rectangular or the overall shapeof the patch can include a distal end width of the patch that isdifferent than a proximal end width of the patch and the patch is threesided or four sided. The overall shape of the patch can be generallycylindrical with a cross section shape that is circular, oval,elliptical or rectangular. Each suture at the surgical repair site canbe passed through a suture conduit. A portion of each suture used at thesuture surgical repair site can be separated from a tissue or a bone ofthe surgical repair site by a portion of the patch.

The patch can contain a patch delivered material. The patch deliverymaterial can be any of a therapeutic agent, a diagnostic agent, or aprophylactic agent maintained within a layer of the patch, a portion ofa layer of the patch or within the patch as a liquid, a powder, a gel, afoam, a particulate media, a solid, a suspended solids, an engineeredparticle or a nanoparticle. The nanoparticle or the engineered particlethe selected from the group consisting of polymeric nanoparticles, metalnanoparticles, gold nanoparticles, PEG coated nanoparticles, liposomes,micelles, quantum dots, dendrimers, and nanoassemblies.

The patch can be configured for designed release of the patch deliverymaterial. The patch can include two or more layers of material. At leastone of the two or more layers of material can be selected to carry apatch delivery material. When the patch is in position at the suturesurgical repair site, the layer selected to carry a patch deliverymaterial can be directly adjacent to the repair site. When the patch isin position at the suture surgical repair site, the layer selected tocarry a patch delivery material can be separated from the surgicalrepair site by another of the two or more layers of the patch. The patchcan be made from materials that are bioabsorbable. The patch can includean upper layer and a lower layer and a layer between the upper layer andthe lower layer, wherein one or more of the upper layer, the lower layerand the layer between the upper layer and the lower layer is configuredto maintain a patch delivery material according to a selected designedtime release of the patch delivery material. The suture conduit can beon, in or within the upper layer. The suture conduit can be on, in orwithin the lower layer. The suture conduit can be on, in or within thelayer between the upper layer and the lower layer. A suture conduit canextend along an outer surface of the patch. The device can furtherinclude one or more attachment features positioned along the patch fromthe proximal and to the distal end to facilitate attachment of the patchto another patch after delivery to the suture surgical repair site.

The patch can be constructed of a biodegradable material having a hybridof a porous material and a material that provide strength construct. Thepatch can be formed from a PLA or PGA mesh and strips of PLA or PGA areprovided for support. The patch can include a component selected forretention of patch delivered materials while another component isselected to provide strength or other functional attributes of thepatch. The patch can include one or more layers of a non-woven mesh, awoven mesh or a knitted multifilament mesh. The device can furtherinclude a portion of the patch folded into a plurality of pleats. Thepatch can be deployed into the surgical site, and at least a portion ofthe plurality pleats remain. The patch can include a scaffold sandwichedbetween outer layers of a non-woven mesh, a woven mesh or a knittedmultifilament mesh. One or more layers of the patch can be joined into aunitary structure by stitching the layers together with fibers,bioabsorbable fibers, or suture, or by joined together by cementing,bonding, embroidering or by thermal processing such as sealing orwelding. The patch delivery material can be selected to promote adesired interaction including an onset, an increase, a decrease or acessation of a related therapeutic, pharmacodynamic, biologic or othereffect upon release at the surgical repair site. The patch deliverymaterial can be selected to promote a desired interaction includingstimulating tissue in-growth, promoting tissue regeneration, preventingadhesion formation, or preventing infection at the surgical site. Onelayer, one portion of one layer, or one portion of a patch can containan autograft material, an allograft material, or an xenograft materialselected for use at the suture surgical repair site. One layer, oneportion of one layer, or one portion of a patch can be configured to apatch delivery material including an agent according to a selecteddesigned time release of the patch delivery material. The agent can beone or more of a analeptic agents; analgesic agents; anesthetic agents;antiasthmatic agents; antiarthritic agents; anticancer agents;anticholinergic agents; anticonvulsant agents; antidepressant agents;antidiabetic agents; antidiarrheal agents; antiemetic agents;antihelmintic agents; antihistamines; antihyperlipidemic agents;antihypertensive agents; anti-infective agents; anti-inflammatoryagents; antimigraine agents; antineoplastic agents; antiparkinson drugs;antipruritic agents; antipsychotic agents; antipyretic agents;antispasmodic agents; antitubercular agents; antiulcer agents; antiviralagents; anxiolytic agents; appetite suppressants (anorexic agents);attention deficit disorder and attention deficit hyperactivity disorderdrugs; cardiovascular agents including calcium channel blockers,antianginal agents, central nervous system (“CNS”) agents, beta-blockersand antiarrhythmic agents; central nervous system stimulants; diuretics;genetic materials; hormonolytics; hypnotics; hypoglycemic agents;immunosuppressive agents; muscle relaxants; narcotic antagonists;nicotine; nutritional agents; parasympatholytics; peptide drugs;psychostimulants; sedatives; sialagogues, steroids; smoking cessationagents; sympathomimetics; tranquilizers; vasodilators; beta-agonist; andoncolytic agents.

In general, in one embodiment, a device to promote healing at a suturesurgical repair site includes a patch having an overall shape, aproximal end and a distal end, and a first suture conduit and a secondsuture conduit along the patch sized to allow passage of a suturethrough each of the first suture conduit and the second suture conduitand permit relative movement of the patch along a suture disposed withineach of the first and the second suture conduits.

This and other embodiments can include one or more of the followingfeatures. When the patch is positioned to promote healing at thesurgical repair site, a suture can be disposed within the first sutureconduit and a suture can be disposed within the second suture conduitextend along the patch beyond the proximal end and beyond the distalend. The first and the second suture conduits can each form a continuousconduit from the proximal end to the distal end of the patch. The firstand the second suture conduits can each form a segmented conduit havingtwo or more suture guide structures spaced along the patch to align thesuture disposed within the two or more suture guide structures of eachof the first and the second suture guide conduits relative to theproximal end and a distal end of the patch. The two or more suture guidestructures can be formed using an element used to assemble the patch.The device where the element can be a filament, at least a portion ofthe patch can be assembled by a stitching process using the filament andthe two or more suture guide structures can be loops of filament formedduring the stitching process. The element can be a fastener having asuture guide formed thereon such that when the fastener is engage with aportion of the patch, the suture guide can be positioned to receive andalign the suture relative to the proximal end and the distal end of thepatch. Each of the first suture conduit or the second suture conduit canbe an aperture formed within the patch extending from the proximal endto the distal end. Each of the first suture conduit or the second sutureconduit can be an elongate hollow structure inserted into the patch. Theelongate hollow member can be present only while loading the patch on tothe suture or while advancing the patch to the surgical repair site. Theelongate hollow member can be present when the patch is secured in placein the surgical repair site. The overall shape of the patch can berectangular or the overall shape of the patch can include a distal endwidth of the patch that is different than a proximal end width of thepatch and the patch is three sided or four sided. The overall shape ofthe patch can be generally cylindrical with a cross section shape thatis circular, oval, elliptical or rectangular. Each suture at thesurgical repair site can be passed through a suture conduit. A portionof each suture used at the suture surgical repair site can be separatedfrom a tissue or a bone of the surgical repair site by a portion of thepatch. The patch can contain a patch delivered material. The patchdelivery material can be any of a therapeutic agent, a diagnostic agent,or a prophylactic agent maintained within a layer of the patch, aportion of a layer of the patch or within the patch as a liquid, apowder, a gel, a foam, a particulate media, a solid, a suspended solids,an engineered particle or a nanoparticle. The nanoparticle or theengineered particle can be selected from the group consisting ofpolymeric nanoparticles, metal nanoparticles, gold nanoparticles, PEGcoated nanoparticles, liposomes, micelles, quantum dots, dendrimers, andnanoassemblies. The patch can be configured for designed release of thepatch delivery material. The patch can include two or more layers ofmaterial. At least one of the two or more layers of material can beselected to carry a patch delivery material. When the patch is inposition at the suture surgical repair site, the layer selected to carrya patch delivery material can be directly adjacent to the repair site.When the patch is in position at the suture surgical repair site, thelayer selected to carry a patch delivery material can be separated fromthe surgical repair site by another of the two or more layers of thepatch. The patch can be made from materials that are bioabsorbable. Thepatch can include an upper layer and a lower layer and a layer betweenthe upper layer and the lower layer, wherein one or more of the upperlayer, the lower layer and the layer between the upper layer and thelower layer can be configured to maintain a patch delivery materialaccording to a selected designed time release of the patch deliverymaterial. The suture conduit can be on, in or within the upper layer.The suture conduit can be on, in or within the lower layer. The sutureconduit can be on, in or within the layer between the upper layer andthe lower layer. A suture conduit can extend along an outer surface ofthe patch. The device can further include one or more attachmentfeatures positioned along the patch from the proximal and to the distalend to facilitate attachment of the patch to another patch afterdelivery to the suture surgical repair site.

The patch can be constructed of a biodegradable material having a hybridof a porous material and a material that provide strength construct. Thepatch can be formed from a PLA or PGA mesh and strips of PLA or PGA areprovided for support. The patch can include a component selected forretention of patch delivered materials while another component isselected to provide strength or other functional attributes of thepatch. The patch can include one or more layers of a non-woven mesh, awoven mesh or a knitted multifilament mesh. The device can furtherinclude a portion of the patch folded into a plurality of pleats. Thepatch can be deployed into the surgical site, and at least a portion ofthe plurality pleats remain. The patch can include a scaffold sandwichedbetween outer layers of a non-woven mesh, a woven mesh or a knittedmultifilament mesh. One or more layers of the patch can be joined into aunitary structure by stitching the layers together with fibers,bioabsorbable fibers, or suture, or by joined together by cementing,bonding, embroidering or by thermal processing such as sealing orwelding. The patch delivery material can be selected to promote adesired interaction including an onset, an increase, a decrease or acessation of a related therapeutic, pharmacodynamic, biologic or othereffect upon release at the surgical repair site. The patch deliverymaterial can be selected to promote a desired interaction includingstimulating tissue in-growth, promoting tissue regeneration, preventingadhesion formation, or preventing infection at the surgical site. Onelayer, one portion of one layer, or one portion of a patch can containan autograft material, an allograft material, or an xenograft materialselected for use at the suture surgical repair site. One layer, oneportion of one layer, or one portion of a patch can be configured to apatch delivery material including an agent according to a selecteddesigned time release of the patch delivery material. When the patch isin position within the surgical space, the width of the distal portionof the patch can be about the same as the spacing between two sutureanchors and the distal portion of the patch is wider than the proximalportion of the patch. When the patch is in position within the surgicalspace, the width of the distal portion of the patch can be about thesame as the spacing between two suture anchors. When the patch is inposition within the surgical space, the width of the distal portion ofthe patch can be about the same as the spacing between the two sutureanchors providing the suture positioned within the first suture conduitand the suture positioned within the second suture conduit. The sutureguided patch selected for delivery into the suture surgical repair sitecan have a patch having a distal end width that corresponds to a spacingbetween two suture anchors positioned within the surgical repair site.The suture guided patch selected for delivery into the suture surgicalrepair site can be a patch having a proximal end width that correspondsto a spacing between two suture anchors positioned within the surgicalrepair site. The two suture anchors can be directly adjacent oneanother. A suture anchor can be between the two suture anchors. One ormore patch delivered materials can be incorporated into the patch duringa manufacturing step or an assembly step, during a step of a surgicalpreparation, before use during a surgical procedure, before placing thepatch into the stowed configuration, while the patch is in a stowedconfiguration before loading the patch into a delivery tool, while thepatch is within a suture loading cartridge, while the patch is loadedinto or coupled to a suture guided patch delivery tool or prior to thepatch being incorporated into a suture based surgical workflow based onan amount of time needed for adding, loading, incorporating or soakingone or more layer of a suture guided patch with a patch deliveredmaterial.

In general, in one embodiment, a method of delivering a suture guidedpatch to a surgical site includes: (1) placing one or more sutureanchors at the surgical site; (2) inserting a suture secured to one ofthe one or more suture anchors through a suture conduit of the sutureguided patch; (3) advancing the patch along the suture in the sutureconduit; and (4) securing the patch in the surgical site using thesuture in the suture conduit.

This and other embodiments can include one or more of the followingfeatures. The placing step can further include pressing or screwing asuture anchor into a bone, a tendon, a ligament, or a muscle at thesurgical site. The method can further include performing one or moresteps of the suture repair procedure before the inserting suture step.The method can further include delivering another suture guided patch byrepeating the inserting step and the advancing step. The method canfurther include joining the patch to the another patch. The joining stepcan be performed using one or more loops provided along the patch. Themethod can further include coupling a modified augmentation device or amodified interposition device to the suture guided patch before or afterthe inserting a suture step and thereafter performing the advancing thepatch step with the modified augmentation device with a modifiedinterposition device. The method can further include performing theinserting a suture step to have a first suture in a first suture conduitand a second suture in a second suture conduit. The patch can be in astowed configuration during at least a portion of the advancing step.The method can further include moving the patch from the stowedconfiguration before reaching the surgical site. The patch can move froma stowed configuration after exiting a working channel of a surgicalinstrument used at the surgical site. The surgical instrument can be oneof an endoscope, an arthroscope, or a trocar. The method can furtherinclude moving the patch from a stowed configuration using a deliverytool. The method can further include loading the patch onto a deliverytool during the inserting step or before the advancing step. The methodcan further include adjusting the position of the patch at the deliverysite using the delivery tool or a positioning tool provided by thedelivery tool. After a step of removing the delivery tool, at least onesuture can be in a suture conduit of the patch. The method can furtherinclude loading the suture guided patch onto a movable leg deliverydevice. The one or more sutures can be alongside the movable legdelivery device. The one or more sutures can be within a channel of themovable leg delivery device. The method can further include adding orincorporating a patch delivered material before the inserting step orwhile the suture guided patch is loaded onto a patch delivery device.The method can further include selecting the suture guided patch basedon one or more of a suture conduit spacing, the suture conduitorientation, a number of suture conduit, a patch size, a patch shape anda designed release of a patch material. The method can further includeone or more of the steps of trimming a patch, shaping a patch or foldinga patch. The one or more steps of trimming, shaping or folding can beperformed before the inserting step, after the inserting step, after theadvancing step or after the securing step. The suture conduit spacingcan be selected based on the spacing between the suture anchors of thesutures in the patch suture conduits. After securing the patch step thewidth of the distal most portion, the patch can be wider than a proximalportion of the patch. After the securing step, the proximal most end ofthe patch can be wider than the distal end of the patch. The delivery ofthe suture guided patch can be a step in a suture-based procedureperformed wherein the surgical site includes a joint, a tendon, a bone,or a ligament. The surgical site can be accessed by an open procedure, aminimally invasive procedure, a natural orifice transluminal procedure,an endoscopic procedure, or an arthroscopic procedure. The method canfurther include loading, providing, incorporating, or encapsulating intothe patch at least one patch delivery material. The patch deliverymaterial can be any of a therapeutic agent, a diagnostic agent, or aprophylactic agent maintained within a layer of the patch, a portion ofa layer of the patch or within the patch as a liquid, a powder, a gel, afoam, a particulate media, a solid, a suspended solids, an engineeredparticle or a nanoparticle. The patch delivery material can be selectedto promote a desired interaction including an onset, an increase, adecrease or a cessation of a related therapeutic, pharmacodynamic,biologic or other effect upon release at the surgical repair site. Thepatch delivery material can be selected to promote a desired interactionincluding stimulating tissue in-growth, promoting tissue regeneration,preventing adhesion formation, or preventing infection at the surgicalsite. One layer, one portion of one layer, or one portion of a patch cancontain an autograft material, an allograft material, or a xenograftmaterial selected for use at the suture surgical repair site. One layer,one portion of one layer, or one portion of a patch can be configured toa patch delivery material including an agent according to a selecteddesigned time release of the patch delivery material. The method canfurther include releasing from the patch at least one patch deliveredmaterial after the securing step. The surgical site can be a shoulder, afoot, an ankle, an elbow, a hand, a wrist, a hip, or a knee.

In general, in one embodiment, a suture guided patch delivery toolincludes an elongate body having a proximal end and a distal end, ahandle on a proximal end, and a pair of moveable legs on the distal endconfigured to receive a suture guided patch and a pair of sutureswherein when the patch and the pair of sutures are loaded onto the toolthe pair of sutures are alongside the pair of movable legs.

This and other embodiments can include one or more of the followingfeatures. The handle can be configured to move the patch and the legsbetween a stowed condition and a deployed condition. The handle can beconfigured to release the suture guided patch from the moveable legs.After the release, the suture guided patch from the moveable legs thepair of sutures can remain within one or more suture conduits of thepatch. The distal end of the legs can be configured to couple to apocket or a cuff in the patch. The handle can be configured to releasethe suture guided patch from the moveable legs by the operation of arelease button. The operation of the release button can cause a pair ofpatch clips or mandibles to open and release the patch from the legs.The amount of movement of the legs can be selected based on the amountof movement for the patch loaded onto the tool to move to a deployedcondition. The moveable legs can be wires biased to move a patch towardsa deployed condition. The moveable legs can be hollow and the suturescan be loaded into the conduit of the legs and the legs can bepositioned within one or more suture loops of the patch. A distalportion of the hollow leg can be reduced to form a shoulder. The patchcan include one or more suture loops sized to engage with the reduceddistal portion of the hollow leg and a proximal portion of a hollow leg.The tool can further include a push rod along the elongate body and canbe engaged with a portion of the patch. A portion of the elongate bodycan be configured to separate to permit each moveable leg to be removedindividually after use. The elongate body can further include a sleeveholding the proximal portion of the delivery tool together. When thesleeve is separated, the moveable legs can be separated. The distalportion of the tool can include a port for adding a patch deliveredmaterial to a patch loaded in the tool. The distal portion of the toolcan be adapted to receive a patch loading cartridge. The patch loadingcartridge can include a port for adding a patch delivered material to apatch loaded in the patch loading cartridge. The proximal end or thedistal end of the suture guided patch delivery tool can be adapted to asuture based surgical repair site for delivery of a sutured guided patchconfigured for use in repair of a shoulder, a foot, an ankle, an elbow,a hand, a wrist, a hip, or a knee.

BRIEF DESCRIPTION OF THE DRAWINGS

FIG. 1 is a posterior-lateral anatomical view of an anatomical humanshoulder.

FIG. 2 is a posterior-lateral anatomical view of a left human shoulderwith a torn supraspinatus tendon.

FIG. 3 is a posterior anatomical view of a right human shoulder with atorn supraspinatus tendon.

FIG. 4 is a posterior-lateral anatomical view of a left human shoulderwith a prior art arthroscopic repair of a torn supraspinatus tendon.

FIG. 5 is a posterior-lateral anatomical view of a left human shoulderwith a prior art patch repair of a torn supraspinatus tendon.

FIG. 6 is a graph illustrating exemplary changes in fraction of tensionforce born by the repaired tissue and the suture repair along with threerepresentative patch delivery designed release profile during anexemplary 8 week time period.

FIG. 7 is a table summarizing three main characteristics of sutureguided patches.

FIG. 8 is a perspective view of a suture guided patch having an ovalform factor and a single suture conduit from the proximal end to thedistal end.

FIG. 9 is a perspective view of a suture guided patch having arectangular form factor and a single suture conduit with a suture shownin an extending through the conduit from the proximal end to the distalend.

FIG. 10 is a perspective view of a suture guided patch having acylindrical form factor and a single oval-shaped suture conduit from theproximal end to the distal end.

FIG. 11 is a side view of a patch delivered and secured over a repairedportion of a rotator cuff.

FIG. 12 is a side view of a pair of suture delivered patches in positionand secured above and below a repaired portion of a rotator cuff.

FIG. 13 is a perspective view of a suture patch as in FIG. 9 in placeand secured above a repaired portion of a rotator cuff.

FIG. 14 is a top view of a rotator cuff repair using sutures from medialand lateral anchor rows and including four, single conduit suture guidedpatches to augment the repair.

FIG. 15 is a top view of a rotator cuff repair using sutures from medialand lateral anchor rows showing the crossed suture pattern without anysuture guided patches.

FIG. 16 is a side view of a rotator cuff repair using sutures frommedial and lateral anchor rows and including single conduit sutureguided patches delivered above and below the rotator cuff to augment therepair.

FIG. 17 is an end view of a suture guided patch having a rectangularform factor as in FIG. 9 including one or more eyelets along the sidesfor connecting to an adjacent suture guided patch.

FIG. 18 is a top view of two suture patches of FIG. 17 aligned side byside permitting engagement of the eyelets. Additionally, a loading tubeis shown within a suture conduit of one of the patches.

FIG. 19 is a top view of two suture patches attached to sutures betweenmedial and lateral row anchors on a rotator cuff. The patches are shownaligned to permit side by side engagement.

FIG. 20 is a top view of a suture patch of hybrid construction of anarray of strips having one material that is porous for holding patchdelivered materials and another material selected to provide overallstructure and strength to the construct.

FIGS. 21 and 22 are top and side views respectively of a suture guidedpatch with 2 suture conduits in a generally triangular shape having awide end and a narrow end.

FIG. 23 is a top view of the patch of FIGS. 21 and 22 shown deployed ona rotator cuff between medial anchors and lateral anchors where the wideportion of the patch is positioned by the medial anchors.

FIG. 24 is a top view of the patch of FIG. 21 with a two-pronged pushertool engaged to a distal edge of the patch.

FIG. 25 is a side view of the pusher tool shown in use in FIG. 24.

FIGS. 26A, 26B and 26C are top views of suture guided patches havingoverall shapes that are approximately triangular with one and wider thanthe other similar to the patch of FIG. 21. FIGS. 26A, 26B and 26C alsoillustrate different types of segmented suture conduits.

FIG. 27 is a top view of a suture guided patch having a pair ofcontinuous suture conduits and an approximately triangular overall shapehaving one end wider than the other.

FIG. 28 illustrates a top down view of a two suture anchor repair of arotator cuff with two sutures crossed and moved outside of the body.

FIG. 29 is the surgical view of FIG. 28 with the two suture anchorsloaded into the suture conduits of a suture guided patch with the patchbeing advanced towards a surgical site.

FIG. 30 is the surgical view of FIG. 29 where the distal end or widestend of the patch is positioned in the surgical site where the suturesemerge from the rotator cuff.

FIG. 31 is a cross section view of the patch placement within thesurgical site as shown in FIG. 30.

FIG. 32 illustrates a top down view of a two suture anchor repair of arotator cuff as shown in FIG. 30 with the narrow end or the proximal endof the patch secured by anchoring the two sutures within the patchsuture conduits to a third bone anchor in the greater tuberosity.

FIG. 33 is a top down view of two bone anchors placed in a medialposition on the greater tuberosity each one having two sutures for atotal of four stands shown having been passed from underneath therotator cuff tendon to the top of the tendon with a suture passer.

FIG. 34 illustrates a top down view of the two suture anchor repair of arotator cuff as shown in FIG. 33 with one strand from each of the twosuture anchors crossed and moved outside of the body.

FIG. 35 illustrates a top down view of a two suture anchor repair of arotator cuff as shown in FIG. 33 after passing two crossed sutures ofthe four suture strands through the suture conduits of a first patch andthe remaining two crossed sutures through the suture conduits of asecond patch. Both patches are shown with the narrow end or the proximalend of the patch secured by anchoring the two sutures within the patchsuture conduits to a third bone anchor in the greater tuberosity.

FIG. 36 is a top view of the surgical site of a suture guided patchbased rotator cuff repair of FIG. 35 where the suture strands have beentrimmed back to or otherwise secured in the surgical site.

FIG. 37 is a top down view of patch cuff repair as in FIG. 36 showing analternative suture guided patch having a segmented suture conduit andthe use of a lateral anchor to secure the narrow or proximal end of thepatch.

FIG. 38 is a top down view at the conclusion of the alternative suturepatch repair of FIG. 37 with two suture guided patches on the rotatorcuff repair. This view also illustrates the suture within the segmentedsuture conduits of both patches as well as the use of the lateral rowanchors instead of adding third anchors as in FIG. 36.

FIG. 39A is a top view of a suture guided patch having a single sutureconduit and a generally rectangular form factor.

FIG. 39B is a top view of a suture guided patch having two alignedsuture conduits and a generally rectangular form factor.

FIG. 39C is a top view of a suture guided patch having two alignedsuture conduits and a generally rectangular form factor where thespacing of the suture conduits is selected to coincide with the spacingof two suture anchors.

FIG. 39D is a top view of a triangular shaped suture guided patch havingtwo divergent suture conduits generally aligned with two sides of thetriangle with the suture conduits closer at the narrow end of the patchand further apart at the wider end.

FIG. 40A is an exploded view of a suture guided patch having an upperlayer and a lower layer with several layers of material between theupper and the lower layer.

FIG. 40B is a perspective view of the layers of FIG. 40A assembled intoa structure suited for use as a suture guided patch.

FIGS. 41A, 41B, 41C and 41D are perspective end views of a multiplelayer suture guided patch each one having a pair of continuous suturechannels in a different layer of the multiple layer structure.

FIGS. 42A -42E illustrate perspective end views of a suture guided patcheach illustrating the location and type of different segmented sutureconduits.

FIG. 43A illustrates a top down view of a suture guided patch for use inthe process of FIG. 74 to select and process a patch before delivery tothe surgical site.

FIGS. 43B, 43C and 43D illustrate top views of different trimming,shaping and folding operations on the patch of FIG. 43A.

FIG. 43E is a perspective view of a folded patch being unfolded at thesurgical site.

FIG. 43F is a top down view of deployed patch that had been previouslytrimmed and sized prior to deployment to a surgical site.

FIGS. 44, 45 and 46 illustrate top down views of patches havingcentrally positioned suture conduits for a selection of aligned,divergent or either aligned or divergent suture conduits, respectively.

FIG. 47A is a top view of a suture patch delivery tool having a handleand an arm projecting from the handle a patch loaded into the distalend. This view also shows the addition of one or more patch deliveredmaterials via a port in the distal end of the tool.

FIG. 47B is a top view of the suture patch delivery tool of FIG. 47Awith a patch within a loading cartridge coupled to the patch deliverytool This view also shows the addition of one or more patch deliveredmaterials via a port in the loading cartridge.

FIG. 48A is a top view of a pincer like mandible or patch release clipsat the end of each of the arms engaged with a suture guided patch. Alsoshown in this view of the stowed patch are three suture loops one at theproximal end and two at the distal end.

FIG. 48B is a top view of the delivery tool and stowed patch of FIG. 48Ashowing looped sutures threaded through each of the suture loops.

FIG. 49 is a top view of the exemplary surgical site of FIG. 29 with thecrossed sutures passed outside the body and ready for loading into thedelivery tool using the looped sutures of FIG. 48B.

FIG. 50 is a top view of the surgical site of FIG. 49 with the crossedsutures passed outside the delivery tool and the delivery tool used toadvance the patch delivery tool and the patch distally towards thesurgical site and just prior to the tool and patch exiting the workingchannel.

FIG. 51 is a top view of the surgical site of FIG. 50 after the patchand delivery tool have been advanced beyond the working channel byoperation of the deploy actuator. Operation of the deploy actuator movedthe patch and the tool along the sutures to position the distal end ofthe patch at the medial anchors as in FIG. 30.

FIG. 52 is a top view of the surgical site of FIG. 51 after operation ofthe release button to open the mandibles or patch clips to separate thepatch from the delivery tool.

FIGS. 53A, 53B and 53C are top views of a moveable biased leg patchdelivery tool with a patch having a cuff or pocket to engage the distalends of the biased legs. FIG. 53A shows the tool and patch advancedalong the sutures and exiting a working channel with the biasing actionof the legs moving the distal end of the patch from a stowed condition.FIG. 53B is a top view of the surgical site of FIG. 53A with the distalportions of the patch and legs of the delivery tool advanced to thesuture anchors. FIG. 53C is a top view of the surgical site in FIG. 53Bwith the legs of the delivery device withdrawn proximally so as todisengage from the pockets or cuffs of the patch.

FIGS. 54A, 54B and 54C are top views of a delivery tool configured toutilize a suture arranged about a portion of an anchor acting as apulley. The pulling suture is wrapped about the anchor and attached to adistal portion of the patch as best seen in FIG. 54A. FIG. 54A alsoshows the tool and patch advanced along the sutures and exiting aworking channel with the patch moving from a stowed condition. FIG. 54Bis a top view of the surgical site of FIG. 54A with the distal portionsof the patch advanced to the suture anchors. FIG. 54C is a top view ofthe surgical site in FIG. 54B with the pull suture separated from theanchor and withdrawn proximally leaving the distal portion of the patchat the medial anchors.

FIGS. 55A and 55B are top down views of an exemplary moveable hollow legpatch delivery tool for delivering a suture guided patch to a surgicalsite. The suture conduit loops of the guided patch are shown loaded onthe distal end of the hollow legs. FIG. 55B illustrates the hollow legdevice and patch in a stowed condition. FIG. 55A illustrates the hollowleg device and patch in a deployed condition.

FIG. 56 is a view of the surgical site similar to that of FIG. 49 withthe crossed sutures outside the body. This view shows the sutures passedcompletely through the hollow legs of the delivery device. The patch onthe distal end of the delivery device is shown in a deployed condition.

FIG. 57 is a view of the surgical site of FIG. 56 the hollow legs of thedelivery device moved together and placing the patch in a stowedcondition. Optionally, the patch may be loaded onto the delivery devicestowed and then the sutures passed through the hollow legs as shown inFIG. 56. This view also show the stowed patch and closed legs of thedelivery device prior to introducing the loaded delivery device into aworking channel for delivery to the surgical site.

FIG. 58 is a view of the surgical site of FIG. 57 after the deliverydevice and the patch have been advanced through and exited the workingchannel of a scope or cannula and moved into a deployed condition. Thedistal end of the patch is also shown in an position approaching theanchors.

FIG. 59 is a view of the surgical site of FIG. 58 illustrating one legof the delivery device moving to adjust a portion of the patch relativeto the anchor or the surgical site.

FIG. 60 is a view of the surgical site of FIG. 58. This view also showsan embodiment of the delivery tool where the tool separates for removalfrom the surgical site after delivery of the patch. The left leg of thetool is shown withdrawn from the body with the right leg in place at thesurgical site. An optional tool is shown in this view that is used tohold the patch in the deployed position relative to the anchors or thesurgical site while the device is withdrawn or to adjust the patch aftertool withdrawal. This view shows the optional tool provided via anothersurgical access but the tool may be provided along with the deliverydevice in other configurations.

FIG. 61 is a top down view of the surgical sites of FIG. 58 afterremoval of the delivery tool and securing the patch in the surgicalsite.

FIGS. 62 and 63 are side and top down views respectively of a hollow legloaded onto the suture guides of a patch. The distal most end of thehollow leg is reduced to produce a shoulder to engage one of the sutureloops to aid movement of the patch along the sutures. These views alsoshow a distal most suture guide loop that is sized to the reducedportion of the hollow leg while additional suture guide loops are sizedto the outer dimension of the proximal hollow leg. The patch isillustrated with one reduced size suture loop in the reduced area.Additional suture loops may be provided along the reduced area towardsthe distal end.

FIG. 64 is a side view of a patch loaded onto a reduced distal endhollow leg as in FIG. 62. This view also illustrates a different lengthof setback from the distal end of the patch to the shoulder. The upperportion of the reduced area is also provided with a shaped tip to permituse of the hollow leg as a positioning tool after or during patchdelivery.

FIGS. 65A and 65B are perspective views of two hollow leg delivery toolembodiments configured to have the legs separate after patch deliveryand for withdrawal from the surgical space. A sleeve positioned aroundthe proximal portion of the legs to maintain the legs in position duringdelivery is shown in each view. FIG. 65A illustrates the sleeve having aperforated segment between each of the proximal portions of the tool.FIG. 65B illustrates a rip cord provided in the sleeve being pulled toseparate the legs for removal.

FIG. 66 is a top down view of a hollow leg delivery device that includesa positioning tool or rod. This view shows the delivery tool and patchin a deployed condition with the positioning tool coupled to a distalportion of the patch.

FIG. 67 is a top down view of a hollow leg delivery device that includesa positioning tool or rod adapted to engage with a pocket or cuffprovided on the patch as shown in FIGS. 53A-53C. This view shows thedelivery tool and patch in a stowed condition with the positioning toolwithin the pocket or cuff of the patch.

FIG. 68 is a flow chart of an exemplary surgical method for placing asuture guided patch in a surgical site.

FIG. 69 is a flow chart of an exemplary surgical method for placing 2 ormore suture guided patches in a surgical site.

FIG. 70 is a flow chart of an exemplary surgical method for placing asuture guided patch in a surgical site including the use of a patch forthe delivery of a modified augmentation device or a modifiedinterposition device.

FIG. 71 is a flow chart of an exemplary surgical method of the movementfrom a stowed condition of a suture guided patch being delivered to asurgical site.

FIG. 72 is a flow chart of an exemplary surgical method for the use ofan exemplary patch delivery tool for delivering a suture guided patch toa surgical site.

FIG. 73 is a flow chart of an exemplary surgical method for the use ofan exemplary moveable leg patch delivery tool for delivering a sutureguided patch to a surgical site.

FIG. 74 is a flow chart of an exemplary surgical method for selectingand optionally preparing a selected patch for suture guided delivery toa surgical site.

DETAILED DESCRIPTION

Embodiments of the present method and apparatus can be used to repairand reconstruct torn ligaments and tendons in a variety of locations ofthe body. The rotator cuff muscles were selected for the exemplaryembodiments because of the complexity of the human shoulder. It will beappreciated that the methods and apparatus according to embodiments ofthe present invention may have many other possible applications.

FIGS. 1-5 are taken from U.S. Patent Application Publication Number2008/0188936, published on Aug. 7, 2008, which is incorporated byreference herein in its entirety. As illustrated in FIG. 1, the rotatorcuff 20 is the complex of four muscles that arise from the scapula 22and whose tendons blend in with the subjacent capsule as they attach tothe tuberosities of the humerus 24. The subscapularis 26 arises from theanterior aspect of the scapula 20 and attaches over much of the lessertuberosity. The supraspinatus muscle 28 arises from the supraspinatusfossa of the posterior scapula, passes beneath the acromion and theacromioclavicular joint, and attaches to the superior aspect of thegreater tuberosity 30. The infraspinatus muscle 32 arises from theinfraspinous fossa of the posterior scapula and attaches to theposterolateral aspect of the greater tuberosity 30. The teres minor 34arises from the lower lateral aspect of the scapula 20 and attaches tothe lower aspect of the greater tuberosity 30. Proper functioning of therotator, 3 to 4 millimeters thick, depends on the fundamental centeringand stabilizing role of the humeral head 31 with respect to slidingaction during anterior and lateral lifting and rotation movements of thearm.

The insertion of these tendons as a continuous cuff 20 around thehumeral head 31 permits the cuff muscles to provide an infinite varietyof moments to rotate the humerus 24 and to oppose unwanted components ofthe deltoid and pectoralis muscle forces. The insertion of theinfraspinatus 32 overlaps that of the supraspinatus 28 to some extent.Each of the other tendons 26, 34 also interlaces its fibers to someextent with its neighbor's tendons. The tendons splay out andinterdigitate to form a common continuous insertion on the humerus 24.The biceps tendon is ensheathed by interwoven fibers derived from thesubscapularis and supraspinatus.

The mechanics of the rotator cuff 20 is complex. The cuff muscles 20rotate the humerus 24 with respect to the scapula 22, compress thehumeral head 31 into the glenoid fossa providing a critical stabilizingmechanism to the shoulder (known as concavity compression), and providemuscular balance. The supraspinatus and infraspinatus provide forty-fivepercent of abduction and ninety percent of external rotation strength.The supraspinatus and deltoid muscles are equally responsible forproducing torque about the shoulder joint in the functional planes ofmotion.

The rotator cuff muscles 20 are critical elements of this shouldermuscle balance equation. The human shoulder has no fixed axis. In aspecified position, activation of a muscle creates a unique set ofrotational moments. For example, the anterior deltoid can exert momentsin forward elevation, internal rotation, and cross-body movement. Ifforward elevation is to occur without rotation, the cross-body andinternal rotation moments of this muscle must be neutralized by othermuscles, such as the posterior deltoid and infraspinatus. As anotherexample, use of the latissimus dorsi in a movement of pure internalrotation requires that its adduction moment be neutralized by thesuperior cuff and deltoid. Conversely, use of the latissimus in amovement of pure adduction requires that its internal rotation moment beneutralized by the posterior cuff and posterior deltoid muscles.

The timing and magnitude of these balancing muscle effects must beprecisely coordinated to avoid unwanted directions of humeral motion.Thus the simplified view of muscles as isolated motors, or as members offorce couples must give way to an understanding that all shouldermuscles function together in a precisely coordinated way—opposingmuscles canceling out undesired elements leaving only the net torquenecessary to produce the desired action.

By contrast, muscles in the knee generate torques primarily about asingle axis of flexion-extension. If the quadriceps pull is a bitoff-center, the knee still extends. Consequently, the human shoulder isa good tool to illustrate the present method and apparatus.

The suprasinatus 28 frequently tears away from the humerus 24 due tohigh stress activity or traumatic injury. FIG. 2 is an anterior view ofa human left shoulder with a torn supraspinatus tendon 28. FIG. 3 is aposterior view of a human right shoulder with a torn supraspinatustendon 28. The supraspinatus 28 has separated from the humerus 24 alongits lateral edge 36 away from its attachment surface or “footprint” inthe greater tuberosity 30.

Surgical repair is usually accomplished by reattaching the tendon backin apposition to the region of bone from which it tore. For thesupraspinatus tendon 28 this attachment region, commonly called the“footprint”, occurs in a feature of the humerus 24 called the greatertuberosity 30. Repair is generally accomplished by sutured fixation ofthe tendon 28 directly to holes or tunnels created in the bone, or toanchoring devices embedded in the bone surface. The methods and patchesdescribed herein may be adapted according to the surgical procedure usedas well as surgeon preference.

FIG. 4 shows a conventional arthroscopic repair of the torn suprasinatustendon 28. The margins of the tear have been brought together at aconvergence line 150 and closed by tendon-to-tendon stitches 152. Thelateral edge 154 has been brought into apposition with the greatertuberosity 30 and secured in place through the use of four sutures 156secured to two bone anchors 158 driven into the bone in the vicinity ofthe greater tuberosity 30. This state-of-the-art repair is subject to a20-60% failure rate, primarily due to suture tear-out from poor qualitytendon tissue.

FIG. 5 shows an improvement to the repair of FIG. 4 with the addition ofa conventional patch augmenting the repair. The edges 162 of thesubstantially planar patch 160 are attached to the rotator cuff tendon20 by sutures 164. As is the typical practice, the sutures used in therepair of FIG. 4 are not used to deliver patch 160. Similarly, patch 160is delivered separately from sutures 164 used to secure the patches.

The surgical repair of a damaged tendon to bone, either performedarthroscopically or utilizing an open technique, is not alwayssuccessful. This is especially true in a chronic setting in which themuscle is atrophied or the tendon is retracted away from its bonyattachment site or both. For this reason, a number of groups havereported on the perioperative use of substances thought to enhance thehealing of a tendon to bone following surgical repair. Substancesreportedly used for this purpose include bone marrow cells, cellulargrowth factors (such as interleukins) and platelets and combinations ofthese and other like substances. The challenge for the surgeon isdelivering these substances in a manner that optimizes the length oftime that these substances remain in the surgical repair site.Embodiments of the patch described herein provide solutions to theaforementioned challenge.

In various aspects, this application provides new medical devices forsuture based repairs that can be delivered via existing sutures used ina procedure. Embodiments of the inventive suture delivered patch devicesare delivered using suture guided techniques along an existing anchoredsuture. The suture is provided within an “in progress” surgicalworkflow. A suture patch includes at least one suture channel that ispositioned relative to the patch so that after movement of the suturepatch along the suture and delivery and deployment into the surgicalsite the patch is in the desired orientation relative to the suture, thesuture anchor, the surgical site and other suture patches (if used) orany augmentation or interposition device (if used). As a result, thepatch may be used to augment the repair of the human rotator cuff andother soft tissue structures. Patch may be constructed from abiodegradable material having a hybrid of a porous material and amaterial that provide strength construct. In one example, the patch isformed from a PLA or PGA mesh and strips of PLA or PGA are provided forsupport. In other words, the patch may include components selected basedon for retention of patch delivered materials while other components maybe selected to provide strength or other functional attributes of thepatch. One or more patches may be linked together at the surgical siteas best seen in FIG. 19, or places in overlapping arrangements as bestseen in FIGS. 36 & 38. Additionally or optionally, the patches may beused alone. Still further, and discussed in greater detail below, thepatch may be preloaded with a patch delivered material designed topromote healing of the tissue or material and/or cells may be addedprior to use.

A patch adapted for suture delivery using the techniques describedherein includes patches of a wide array of different size, shape,composition and construction. A patch may have a unitary construction ofone or substantially one mostly unitary material, a composite or mixedmaterial, formed of one or multiple layers including “sandwiched” orrepeating or alternating stacks of different types of layer materialsand hybrid designs including combinations of the above.

Suture guided patches, referred to generally as patches, foradvantageous delivery using the suture-based delivery techniques may, incertain embodiments, be formed from absorbable polymers, biocompatibleand bioabsorbable polymer fibers and other materials which areabsorbable and suited to the repair of rotator cuff tears and othertendon or ligament repairs. In one aspect, a patch comprises absorbablepolymer or polymer fiber or structures that provide sufficient initialstrength and shape retention to move from stowed to deployed, expandinto deployed shape and retain deployed shape at the surgical site,withstand forces relative to the suture including the relative movementalong the suture during deployment, loading forces for repair providedby the use of the suture (i.e., tightening), to stand loading of thesuture once anchored in place and remaining in place and with enoughshape retention during the ongoing healing process at the surgical siteand the movement of the joint or repaired surface as a result ofphysical therapy and/or increased activity post-surgery. As such, it isto be appreciated that with regard to the strength of materials used tojoin and hold the surgical repair, the suture delivered patch devicesprovide an insubstantial amount of assistance or, more correctly, whencompared to compared to the loads of the suture, are of no consequenceto the forces to maintained in a successful surgical repair.

In contrast to conventional suture delivery techniques where patches arepulled through working channels, inventive techniques described hereinare similar to those delivery techniques used in vascular surgerythrough the use of guide wires and designs of devices that may be stowedin a compact form and then deployed into a larger size, shape whendelivered to the appropriate surgical site. In much the same way,various alternative designs of suture guided patches place the suture inthe position of a guidewire with patches designed for delivery throughthe working channel of instruments and then for a controlled release ator while being delivered to the surgical site. The use of multiplesmaller, overlapping patches replaces the conventional approach (i.e.,“one repair-one patch”) where a single large patch sized to nearlycompletely cover the repair is used. As a result, the suture deliveredpatches along with the variety of patch delivered materials providesmethods for easier to deliver patches that integrate into the existingsurgical workflow also providing greater ease in adapting patch size,surgical repair coverage, as well as patient specific patch deliveredmaterial combinations for greater surgical options and flexibility.

The patch should have sufficient structural integrity to allow them tobe retained by sutures without tearing. The patch should also havesufficient initial strength to retain the shape of a suture conduit andto prevent a tear as a result of movement of the patch along the suture.Additionally, the patch should have sufficient initial strength tosupport movement of the patch in a stowed configuration with respect tothe surgical delivery system or associated delivery tool. In one aspect,a patch is provided in one of a number of pre-determined widths such as1.0 cm, 1.5 cm or 2.0 cm to accommodate estimated anchors or surgicalsite spacing ranging between 0.8 cm-1.5 cm. In still another aspect, apatch width is selected to approximate a spacing between suture anchors.The dimensions of a specific patch embodiment will vary according to theparticular use of the patch. The patch may be selected to be wider thanthe estimated spacing or contain pleats. As such, the actual patch widthis fully deployed (i.e., laid flat) would be wider than the deployedspan at the surgical site. In one embodiment, a patch may have a pre-setlength ranging from 1.5-2.0-2.5 cm or other pre-set lengths depending onuse.

(The patch should be designed to retain strength long enough fordelivery and movement/manipulation during implantation at the surgicalsite as well as to remain in place during long enough to allow the bodyto heal, and permit the patient to begin physical therapy and return tonormal activity. The patches should ultimately be absorbed completely orsubstantially in relation to the delivery or substantially completedelivery of the patch delivered materials provided by the patch. Thetime period for the substantial absorption of the devices is lesscritical than the patch having sufficient strength retention to remainin place until the full material payload is delivered to the surgicalsite.

In one specific embodiment, the suture delivery patch includes acomposition of the device having a non-woven scaffold of sandwichedbetween outer layers of a knitted multifilament mesh. In one additionalembodiment, the device is prepared from multifilament yarn. In oneaspect, the patch is pleated to provide additional material at thesurgical site. In one aspects the pleats formed in the patch are ofsufficient number or size that a portion of the pleats remain in apleated condition after the patch is deployed in the surgical site andreleased from the delivery tool or device. In another aspect, all orsubstantially all of the pleats formed in a patch device are removedwhen the patch is deployed in the surgical site and released from thedelivery tool.

In one aspect, a suture patch is assembled by sandwiching a non-wovenmesh between knitted multifilament meshes to form a 3-ply construct andthereafter modifying the construct as described herein to provide asuture channel as well as provide for appropriate attachment to anddelivery using a patch delivery device. Other combinations of thenon-woven mesh and knitted multifilament mesh may also be used,including, but not limited to, a 2-ply construct comprising a knittedmultifilament mesh with a non-woven mesh in multiple different numbersof piles alternating between different types such as non-woven, woven,knitted and the like. The thickness, order, size, dimension andorientation of each layer relative to the overall patch and adjacentlayers may be adjusted depending upon the design characteristics ofparticular patch (see FIGS. 40A, 40B). Still further, a patch may alsobe formed from other fiber-based constructs, including monofilamentmeshes and terrycloth constructs. In these and in other variations, thevarious layers of the patch may be held together, for example, bystitching the layers with fibers, bioabsorbable fibers, or suture, or byother suitable methods such as bonding, embroidering or thermal weldingdepending upon the design characteristics of a patch. If desired, thepatch may be further reinforced with mono- or multifilament fibers.Similar techniques may be used to provide or form on a patch one or moresegmented suture channels (see FIGS. 42C, 42D and 42E), form or affixone or more continuous suture channels as best seen in FIGS. 41A-41D orprovide loops suited for joining patches together (see FIGS. 17 and 18)or as a process to join a suture guided patch to an modifiedaugmentation device or modified interposition device as described above.

In one aspect, the suture delivered patch has enough structure so thatthe patch does not bind or bunch in a stowed condition nor tear whenmoving to a deployed condition. Embodiments of the suture deliveredpatch will fold and unfold without tearing and will retain shape throughthe loading delivery and deployment process. Additionally, the patch isnot bulky and may be compressed when in a stowed condition so that itmay be delivered using the various arthroscopic or minimally invasivetechniques described herein. The patch is a controlled release reservoirfor the patch delivered materials and as such may be thinner and have alower strength properties than other implanted patch materials, or asfound in conventional augmentation devices and interposition devices.Additionally, the patch may remain in the deployed condition whenunloaded with enough strength and structural integrity to remainunloaded but still be pliable and formable by the surgeon to adjust thelocation of the patch at the surgical site. The various patch designsalso remain in a deployed condition over time as joint healing andrecovery begins. As described above, the sutures carry the load of therepaired tissue. As such, the patch needs only sufficient strength ofsufficient duration to remain in position while the joint begins to moveand the loading state changes as the patient undergoes physical therapyand the joint healing process progresses. Still further, the degradationor bio absorption of the support structure of the patch is selected andadjusted according to the rate of delivery of the material loaded intothe patch as well as the rate of designed release of the materials fromthe patch. It is to be appreciated that the patch support structurewhile bioabsorbable remains with sufficient integrity in order tosupport the structure, matrix or portion of the patch that is loadedwith the patch delivery material.

Additional characteristics of the inventive suture delivered patchinclude: ability to hold and release in a controlled fashion the loadedpatch delivered material; ability to move relative to suture duringdelivery without tearing or shredding; ability to carry no more than 10%of loading from tension of the suture; aid in repair process includingthe growth of tissue; has enough structural integrity to be positionedaccurately during deployment not so flimsy that it simply peels up or sothen that it tears rather than unfolds on delivery. Still further, asbetween the patch and the suture, the suture is performing the repair bymaintaining the bone and soft tissue in apposition while the patch aidsin the healing process.

A number of different patch form factors are provided by the variousdifferent embodiments of the suture patch. One form factor is that of apatch which will work alone or be employed with similar patchconfigurations but each one operating independently at the surgicalsite. Another form factor relates to various ways of joining togetherseparate patches after delivery to the surgical site. In one aspect,loops or other structure provided alongside the adjacent portions of thepatches may be used to join the patches together, typically by anadditional suture operation. Still another form factor relates to theplacement of the suture conduit relative to the patch. In one formfactor, the conduit runs through the entire length of the patch. Thesuture conduit may be formed by simply making an appropriate opening inthe patch. In another embodiment, a suture conduit is provided byinserting a separate conduit or tube into and along the patch to providea guide channel for the suture. In still others, the suture conduit isnon-continuous or segmented whereby hoops, loops of suture or otherguides are provided at a spacing along the patch and thereafter used tohold the suture or a delivery tool used with the suture. Still anotherform factor includes a suture delivered patch with a suture conduit thatis attached, joined, stitched or otherwise provided with an augmentationdevice or an interposition device whereby the patch provides forsuture-based delivery of the augmentation or interposition device

“Biocompatible” as used herein means the biological response to thematerial or device is appropriate for the device's intended applicationin vivo. Any metabolizes of these materials should be biocompatible.

“Strength retention” as used herein refers to the amount of strengththat a material maintains over a period of time following implantationinto a human or animal. For example, if the tensile strength of anabsorbable mesh or fiber decreases by half over three months whenimplanted into an animal or human, the mesh or fiber's strengthretention at 3 months would be 50%. As described herein, the strength ofthe patch is related to its ability to withstand delivery along thesuture and the movement of the surgical site post-surgery. In contrastto other patches, and joining structures designed for providing strengthto the surgical repair, embodiments of the inventive suture guided patchdo not play a significant role in providing the force needed or to bearthe load imparted in a surgical repair. Typically, the suture used todeliver the suture guided patch-often in combination with one or moreother sutures-bear the loads and holds the repaired tissue, bone,ligament, tendon as required at the surgical site. The suture deliveredpatch assists in promoting the healing process after surgery.

Absorbable as used herein means the complete or substantially completedegradation of a material in vivo, and elimination of its metabolitesfrom an animal or human.

The suture delivery surgical repair patches are adapted for use withsuture anchors. Suture anchors are available in a wide array of designs.The devices and methods of patch placement described herein areadaptable to virtually any approved suture anchoring system includingsmooth or threaded metallic or polymer bone fixation fastener. A sutureanchor is intended to reattach soft tissue to bone in orthopedicsurgical procedures. The system may be used in either arthroscopic oropen surgical procedures. After the anchor is deployed in the bone, thefloating sutures provided by the suture anchor can be used to reattachsoft tissue, such as ligaments, tendons, or joint capsules to the bone.According to the various embodiments of the present methods, theanchored sutures thereafter act like a guide wire to provide fordelivery of embodiments of suture patches into the surgical site whilespanning between two implanted anchors. As a result, the suture anchorsystem thereby stabilizes the damaged soft tissue, in conjunction withappropriate postoperative immobilization, throughout the healing periodwhile also providing one or more arthroscopically delivered patches.Advantageously, embodiments of the inventive patches described hereinare adapted and configured for delivery along existing anchored suturesin the existing surgical workflow. In some embodiments, the patchesdelivered using existing anchored sutures are secured to the surgicalsite when the sutures themselves are secured in the surgical site. Thesuture anchors described herein are intended to be used for thereattachment of soft tissue to bone and the sutures provided for thispurpose are employed as described in embodiments of the inventivesurgical repair patch methods to also secure the surgical repair patch.In some embodiments the sutures are secured into the surgical fieldusing a friction fit into the target bony anatomy. Exemplary sutureanchors include solid core anchors or hollow core style anchors orvariable interior anchor materials of a hybrid design.

The suture anchor size may be selected upon a number of factors suitedto the surgical site and procedure being performed. Similarly, the sizeand type of sutures provided with the anchor may be selected based onthe estimated suture length needed for the repair along with anyconsiderations for anchoring the repair patch. In one aspect, there isprovided a pair of floating sutures on each suture anchor provided intothe surgical site. In one aspect two floating sutures are provided oneach anchor and the colors and types of sutures may be selected from twodifferent solid colors, two different braided colors, a co-braid colorcombination such as black/white, blue/white, green/white, or othercombinations suited to surgeon preference or adaptation of the patchrepair method to a particular patient or surgical site or procedure.

In a number of different alternative embodiments, a variety of differenttypes and constructs of the inventive patches described herein may beused with any of a number of different commercially available sutureanchors and sutures. In one or more different embodiments, the sutureprovided by the suture anchor is a nonabsorbable suture or an absorbablesuture and is provided as a single filament, multifilament or braidedconstruction. Additionally or optionally, sutures can be comprised ofsingle polymers or polymer blends. Nonabsorbable sutures are made frominert materials including, for example, nylon (available commercially asDermalon, Monosol, Surgilon, Nurolon and Ethilon), polybutester(available commercially as Novafil, and Vascufil), polyester (availablecommercially as Surgidae, Ticron and Cottony II), polyethylene(available commercially asMaxBraid, Mersilene and Ethibond), and polypropylene (available commercially as Surgipro, Deklene and Prolene). Inother embodiments, an absorbable suture is fabricated from one or one ormore biodegradable polymers. Common biodegradable polymers used insutures include polyglycolic acid (available as Dexon S), PLLA, PDO(available as Monodek and Ethicon) and poly-D, L. lactic acid and theircopolymers. Still further, in some embodiments, an absorbable suture caninclude modifications to improve know tying properties and tensilestrength, for example, PGA with a polycaprolactone PGA coating (such asBondek Plus), poliglecaprone 25 (available as Monocryl), polycaprolate(available as Dexon II), PDO with polyglactin 910 coating (such asVieryl) and polyglytone (such as Caprosyn).

In still other alternative embodiments, the suture anchors providefloating sutures having monofilament or braided suture structures. Inone aspect, a braided polyester suture may be coated with polybutylenefor a slicker outer surface to improve arthroscopic knot tying. Otherbraided structures may also include a coating of PTFE as is common inthe commercially available Tevdek and Polydek sutures. In still otheraspects, the braided suture may include a core material with the braidwrapped around core. The suture may also be an ultra high molecularweight polyethylene (UHMWPE) surrounded by a polyester braid as isavailable in a Fiber Wire suture. Additionally or optionally, a braidedsuture may be provided composed entirely of an ultra high molecularweight polyethylene such as is available as ForceFiber, MagnumWire,Ultrabraid and Hi-Fi. Orthocord is another UHMWPE suture with a PDO coreand a coating of polyglactin 910. Any of the above described sutures mayalso be coated with an appropriate antimicrobial coating to inhibitbacterial growth within the suture material structure.

In various alternatives, a suitable suture anchor may be provideddepending upon the needs of the damaged tissue being repaired. Theanchor is pre-loaded with a suture at the time of manufacture or at thetime of surgery via an eyelet or other aperture or suitable technique tojoin one or more sutures to the anchor for delivery to the surgicalsite. In general, a suture anchor may be described as a screw orthreaded anchor or an impaction or thread less anchor based on the wayan anchor is fixed to the target bone. Still further, a suture anchormay also be classified based on how sutures are tightened, typically, asnormal anchors or knotless anchors. Knotless anchors include aneyelet-suture system rendering knot tying unnecessary. Still another wayof categorizing suture anchors is based on material. In someembodiments, the suture anchors may be formed from bioinert andbiocompatible metals such as titanium, stainless steel and alloysthereof. In some embodiments, the suture anchor is made of abioabsorbable material or combination. Exemplary materials include PGA,polylactic acid (PLA) a copolymer of PLA and PGA (PLGA) or a combinationof the two. Additional alternatives include anchors that arebiocomposites having a bioabsorbable polymer and an osteoconductivebioceramic or such materials in combination to accelerate bone formationand mineralization by the timed degradation of the ceramic along withthe polymer. Still another alternative suture anchor material ispolyetheretherketone (PEEK).

The suture delivered patches are implanted during surgery, at or inplace of the damaged tissue, via delivery using the existing suturesalready in use during the repair procedure. As such, an embodiment ofthe suture patch based device may be deployed into the surgical site ina guided and direct manner during any of a wide variety of surgicalprocedures such as an open procedure, a “mini-open” procedure, aminimally invasive surgical procedure, a natural orifice transluminalsurgical procedure (i.e., any of the various NOTES procedures), a singleport access procedure, an endoscopic procedure, an arthroscopicprocedure or any other scope based procedure by utilizing one or moresutures already in use during the procedure, anchored in place withinthe surgical site, or provided as part of the surgical workflow. Byutilizing the advantageous designs of the inventive path, the one ormore sutures already provided are used like guidewires to directmovement of the patch to the desired location within the surgical site,provide for proper placement and alignment with respect to the surgicalrepair site or other patches if more than one patch is used. In oneaspect, especially for any scope delivered procedure such as by anendoscopic or an arthroscopic delivery, the suture patch and deliverytool is readily closed into a stowed condition where the device isclosed or in reduced profile with the patch suitably compressed, rolledor folded alongside the delivery device to a size dimensioned to permitpassage through a working channel of the scope and to the surgical site.In one aspect, a delivery tool and a patch are threaded onto one or moresutures, placed into a stowed condition and advanced through a workingchannel of a scope while remaining in the stowed configuration andadvancing along the one or more sutures towards the surgical site. Insome embodiments, one or more or a combination of patch deliveredmaterials, including therapeutic, diagnostic, and/or prophylacticagents, cells or whole tissues, are added for incorporation into andsubsequent designed release or delivery to the surgical site using thesuture patch. By way of example, patch delivered materials areincorporated into the patch during manufacturing or assembly or as partof a surgical preparation or before use procedure or before placing thepatch into the stowed configuration or while in a stowed configurationbefore loading the patch into a delivery tool or while waiting to beincorporated into the surgical workflow. In various alternativeembodiments, these materials can be used, for example, to render thesuture delivered devices radio-opaque, simulate tissue in-growth,promote tissue regeneration, prevent adhesion formation, preventinfection, provide additional reinforcement, to another suture deliveredpatch.

Additional examples of patch delivered materials, include therapeutic,diagnostic, and/or prophylactic agents, cells or whole tissues,regardless of form, whether in liquid, powder, gel, foam, particulatemedia, solids or suspended solids, including engineered particles ornanoparticles designed to release one or more of the materials,including various types of encapsulation as well as factors for designedrelease of material at the surgical site.

As used herein, nanoparticles relate to a form of structures with sizesin the nanometer (nm) range. In principle any collection of atoms bondedtogether with a structural radius of <100 nm can be considerednanoparticles. In various embodiments of suture guided patch,nanotechnology based materials or structures are provided in order thatthe interaction of the patch and the surgical site may take advantage ofany of a variety of biological and medical processes that occur atnanometer scales. It is generally believed that among the approaches forexploiting nanotechnology in medicine, nanoparticles offer some uniqueadvantages as sensing, image enhancement, and delivery agents. Severalvarieties of nanoparticles that may be adapted and configured for use inpatch delivered materials, include by way of example, polymericnanoparticles, metal nanoparticles, gold nanoparticles, PEG coatednanoparticles, liposomes, micelles, quantum dots, dendrimers, andnano-assemblies. Various alternative embodiments of suture guidedpatches include various aspects of nanoparticles or nanoparticles basedmaterial delivery including additional details provided in publishedUnited States Patent Application Publication Number US 20130004651 and“Nanoparticle—based targeted drug delivery” by R. Singh and J. Lillard,Jr. (Exp Mol Pathol. 2009 Jun.: 86(3): 215-223, published online on Jan.7, 2009.

Those of ordinary skill will appreciate the cooperative manner withwhich the embodiment or characteristics of a patch are modified basedupon the type of patch delivered material selected, suitable structuresfor incorporation of the material into the patch, the designedcontrolled release curve or delivery profile and the like. Designed timerelease or modified release of patch delivered materials is a deliberatemodification of the release rate of patch delivered materials based on anumber of factors including, for example, the surgical and patientspecific circumstances where the suture patch will be used, the desiredinteraction with the surgical site, including onset, increase, decreaseor cessation of a related therapeutic, pharmacodynamic, biologic orother effect. Accordingly, designed release, as used herein, relates tothe manner by which patch delivered materials are introduced to thesurgical site according to any of a variety of widely used deliverymodes including controlled-release, modified release, extended-release,delayed-release, targeted release or other forms of materialintroduction based on release technology along with associatedmechanisms of action appropriate to suture patch delivered materials. Insome embodiments, designed time release also takes into considerationthe composition and structure of a suture guided patch, including forexample the degradation profile of structural materials used in thepatch, along with the structure and properties of the portion of thepatch used to store and release the patch delivered materials.

As a result, a wide array of different patch delivered materials-aloneor in combination-may be incorporated into and released by design fromthe various embodiments of the suture delivered patch. Still further,these materials can be used, for example, to render the patchesradio-opaque, stimulate tissue in-growth, promote tissue regeneration,prevent adhesion formation, prevent infection, and the like dependingupon, for example, patient needs, type of surgery, surgeon preferenceand the like.

Exemplary agents that are part of patch delivered materials include, butare not limited to, analeptic agents; analgesic agents; anestheticagents; antiasthmatic agents; antiarthritic agents; anticancer agents;anticholinergic agents; anticonvulsant agents; antidepressant agents;antidiabetic agents; antidiarrheal agents; antiemetic agents;antihelmintic agents; antihistamines; antihyperlipidemic agents;antihypertensive agents; anti-infective agents; anti-inflammatoryagents; antimigraine agents; antineoplastic agents; antiparkinson drugs;antipruritic agents; antipsychotic agents; antipyretic agents;antispasmodic agents; antitubercular agents; antiulcer agents; antiviralagents; anxiolytic agents; appetite suppressants (anorexic agents);attention deficit disorder and attention deficit hyperactivity disorderdrugs; cardiovascular agents including calcium channel blockers,antianginal agents, central nervous system (“CNS”) agents, beta-blockersand antiarryhythmic agents; central nervous system stimulants;diuretics; genetic materials; hormonolytics; hypnotics; hypoglycemicagents; immunosuppressie agents; muscle relaxants; narcotic antagonists;nicotine; nutritional agents; parasympatholytics; peptide drugs;psychostimulants; sedatives; sialagogues, steriods; smoking cessationagents; sympathomimetics; tranquilizers; vasodilators; beta-agonist; andtocolytic agents.

For example, an antibiotic may be added to the patches to prevent ortreat an infection. In one embodiment, the suture delivered patchcontains a biologically derived implant material. Various differentembodiments of the inventive suture guided patch may also incorporateautograft, allograft, and/or xenograft materials. Exemplary biologicallyderived implant materials have been developed, including allografts,(e.g. Wright Medical GraftJacket™. [Human Dermis]) and xenografts, (e.g.Depuy Restore™. (Porcine SIS), Arthrotek Cuff Patch™. [Porcine SIS],Stryker TissueMend™. [Fetal Bovine Dermis], Zimmer Permacol™. [PorcineDermis], Pegasus Orthadapt™. [Equine Pericardium], Kensey NashBioBlanket™. [Collagen], CryoLife ProPatch™. [Bovine Pericardium]). Inaddition to providing structural reinforcement, these materials areintended to repopulate the host ligament or tendon tissue withappropriate ligament or tendon cells as they are absorbed by the body.

FIG. 6 is a graph illustrating exemplary changes in fraction of tensionforce born by the repaired tissue and the suture repair along with threerepresentative patch delivery designed release profile during anexemplary 8 week time period. In use, the various embodiments of thesuture guided patch are prepared with both the structural bio absorptionof the patch material itself as well as the designed release of thepatch delivered material. FIG. 6 is a graph at provides an exemplaryrepresentation of the absorption rate of sutures used in the procedureas indicated by the relative strength of the sutures (line 20) to thejust repaired tendon or structure (line 18). As can be seen in theseillustrative curves, the tension loads are born by the sutures at timet=0 but then shift to the repaired structure gradually as the site healsand the sutures are absorbed. FIG. 6 also shows three differentexemplary designed release rates of patch delivered materials. Aspecific embodiment of a suture guided patch may be designed to providea designed release in any of a number of different profiles. Curve Aillustrates a time delayed release of patch delivered materials at alonger time interval or several days to once a week. Curve B illustratesanother time release of patch delivered materials with smaller and morefrequent doses than shown in Curve A. In contrast to Curves A and B,Curve C illustrates an exemplary designed release of patch deliveredmaterials that is nearly constant over a sustained period such as thefirst few weeks after surgery. Curves A, B and C along with curves 18and 20 are illustrative only to show how the designed release of patchdelivered materials may correspond to the bioabsorption of suture orother structure used in the repair of tissue as described herein.

FIG. 7 is a table summarizing various properties of suture guidedpatches including patch structure, as well as the various formulationand types of agents provided as patch delivered materials.

Suture Guided Patches Having a Single Suture Conduit

Various alternative embodiments of the present suture guided patchinvention are embodied as disclosed and illustrated in the attachedFIGS. 8-20 and accompanying description. In one aspect of the presentinvention a suture guided patch is embodied in a suture sleeve that hasa single suture conduit that surrounds a suture for incorporating and/ordelivering chemical and/or biological agents to a suture site. Thesuture sleeve can be made from a biodegradable and/or permanent basematerial, be porous and/or configured as a scaffold to incorporate anddeliver biologics to a site (i.e., patch delivered materials see outersurface 60 of FIG. 10). The suture sleeve can be used, by way of exampleand not by way of limitation, for any application that involves a sutureor has the need for a delivery vehicle for delivering a chemical and/orbiological agent e.g., rotator cuff repair, soft tissue repair, ACLreconstruction, quadriceps tendon repair, ankle tendon repair, etc. Thesuture sleeve is preferably delivered and assembled to the suturearthroscopically. Preferably, the suture sleeve is formed from collagen,submucosa or Marlex®, but can alternatively be formed from any othersuitable material.

In accordance with another embodiment, the present invention is embodiedas disclosed and illustrated in FIGS. 8, 9 and 10. FIG. 8 is aperspective view of a suture guided patch having an oval form factor anda single suture conduit from the proximal end to the distal end. FIG. 9is a perspective view of a suture guided patch having a rectangular formfactor and a single suture conduit with a suture shown in an extendingthrough the conduit from the proximal end to the distal end. FIG. 10 isa perspective view of a suture guided patch having a cylindrical formfactor and a single oval-shaped suture conduit from the proximal end tothe distal end.

This and other embodiments may be used to augment the repair of thehuman rotator cuff and other soft tissue structures. The device can beapplied arthroscopically or during open surgery. FIG. 11 is a side viewof a patch delivered and secured over a repaired portion of a rotatorcuff. FIG. 12 is a side view of a pair of suture delivered patches inposition and secured above and below a repaired portion of a rotatorcuff. FIG. 13 is a perspective view of a suture patch as in FIG. 9 inplace and secured above a repaired portion of a rotator cuff.

The suture guided patch includes a biodegradable material. The materialcan be a hybrid of a porous material and a material that providesstrength to the construct. Such as, for example, a PLA or PGA mesh andstrips of PLA or PGA. FIG. 20 is a top view of a suture patch of hybridconstruction of an array of strips having one material that is porousfor holding patch delivered materials and another material selected toprovide overall structure and strength to the construct. The mesh can beinfused with a solution that can be cells such as stem cells or growthfactors or both (see materials 60 in FIG. 10). The device is shaped inrectangular form as shown in FIGS. 9, 13, 18, 19, and 20. There is asuture conduit 52 which is a hole in the center of the device that canaccommodate a suture 8 as shown in FIG. 9. A shuttle tube 58 may beplaced in the hole 52 to facilitate the passing of the suture throughthe center of the device. A shuttle tube 58 is shown in place in FIG.18. The tube may then be removed after passing the suture. Suture guidedpatches or sleeves 50 may be linked together after they have been passedby passing a suture 8 through eyelets 62 located on both sides of thepatch 50. The suture delivered patch may be preloaded with a materialdesigned to promote healing of the tissue or material and/or cells maybe added in the operating room (i.e., patch delivered materials).

FIG. 14 is a top view of a rotator cuff repair using sutures from medialand lateral anchor rows and including four, single conduit suture guidedpatches to augment the repair.

FIG. 15 is a top view of a rotator cuff repair using sutures from medialand lateral anchor rows showing the crossed suture pattern without anysuture guided patches.

FIG. 16 is a side view of a rotator cuff repair using sutures frommedial and lateral anchor rows and including single conduit sutureguided patches delivered above and below the rotator cuff to augment therepair.

Embodiments of the suture patch may be configured for being joined atthe surgical site and include features for that purpose. FIG. 17 is anend view of a suture guided patch 50 having a rectangular form factor asin FIG. 9 including one or more eyelets 62 along the sides forconnecting to an adjacent suture guided patch 50. FIG. 18 is a top viewof two suture patches of FIG. 17 aligned side by side permittingengagement of the eyelets. Additionally, a loading tube 58 is shownwithin a suture conduit of one of the patches. The loading tube may beused to thread suture into a suture conduit formed within a patch or thetube may form the suture conduit or also function as a delivery tool tofacilitate advancing the patch along the suture to the surgical site.One or more patches may then be arranged in the surgical site as needed.FIG. 19 is a top view of two suture patches attached to sutures betweenmedial and lateral row anchors on a rotator cuff. The patches are shownaligned to permit side by side engagement using eyelets 62 or otherstructures provided for that purpose.

In still another aspect, a pair of continuous or segmented sutureconduits may be arranged (i.e., aligned or diverging when viewed fromproximal to distal) to provide two sides of a patch. These singleconduit patches or two suture sleeves may be connected by attaching awoven scaffold or structure between and to them to be used to enhancethe surgical repair of a damaged tendon to bone. As described above, thepatch device can be made of biodegradable material or non-biodegradablematerial or a combination of the two. The device may be coated with asubstance or a combination of substances thought to enhance the healingof a damaged tendon to bone as detailed in the patch delivered materialssection above.

Suture Guided Patches Having Two Suture Conduits

FIGS. 21 and 22 are top and side views respectively of a suture guidedpatch with 2 suture conduits in a generally triangular shape having awide end and a narrow end. FIGS. 26A, 26B and 26C are top views ofsuture guided patches having overall shapes that are approximatelytriangular with one and wider than the other similar to the patch ofFIG. 21. FIGS. 26A, 26B and 26C also illustrate different types ofsegmented suture conduits.

FIG. 27 is a top view of a suture guided patch having a pair ofcontinuous suture conduits 52 and an approximately triangular overallshape having one end wider than the other. Segmented suture conduits 54are shown in FIGS. 21, 22, 23, 26A, 26B, and 26C. Segmented sutureconduits have a number of suture guides 56 spaced along the patch. Aswith previous embodiments, suture 8 is advanced from the proximal todistal end of the patch using the continuous conduit 52 or via the oneor more loops 56 of a segmented conduit 54

An additional alternative embodiment includes a multisided device formedby joining two single conduit patches or two suture sleeves that areconnected by a woven scaffold to be used to enhance the surgical repairof a damaged tendon to bone. This patch and the others above can be madeof biodegradable material or non-biodegradable material or a combinationof the two. The device may be coated with a substance or a combinationof substances thought to enhance the healing of a damaged tendon tobone. Some examples of these substances include but are not limited tocells, growth factors and other blood products. The device may beutilized in either an arthroscopic repair or an open repair of a damagedtendon to bone. In an aspect of the embodiment of the invention, thedevice is used to enhance the repair of one or more rotator cufftendon(s) in which two sutures from one or more medial anchor(s) arepassed through the damaged tendon in a mattress fashion and are thenpassed sequentially through the two suture sleeves of the device, andfinally said two sutures are secured to bone with a more laterallypositioned anchor. In accordance with another aspect of the embodimentof the invention, the device is secured between one or more mediallypositioned and laterally positioned anchors and is used to bridge a gapduring the repair of one or more damaged tendon(s) to bone. FIG. 23 is atop view of the patch of FIGS. 21 and 22 shown deployed on a rotatorcuff between medial anchors and lateral anchors where the wide portionof the patch is positioned by the medial anchors.

As is illustrated in these embodiments, the suture guided patch can beconfigured to have a triangular shape, with one end wider than theother. Depending upon desired deployment into a surgical site, the patchmay be deployed to engage with two medial anchors and a lateral anchor,or vice versa. According to the desired configuration, the patch largerend can be positioned medially and the smaller end secured laterally.The patch is configured to have either a continuous suture conduit 52 asshown in FIG. 27 or the suture conduit can be segmented 54 and beconfigured instead with a series of loops 56 through which the suture 8passes. The patch can be configured to include a woven scaffold to whicha suture conduit is added. As such, the patch can also be configured sothat the suture 8 is threaded through the scaffold with filament loopsas in FIG. 21, 22 and FIG. 26C or with thin hoops as in FIG. 26A and26B. As described below, there are many variations for providing sutureconduits for suture guided patches.

In some embodiments, there may be provided a two pronged pusher to pushthe device through a cannula. The pusher or a patch positioning devicemay also be provided and can be shaped like a two pronged fork that isdesigned to push the device through an arthroscopic cannula after thesuture guided patch has been loaded onto two sutures outside the body.The patch positioning device similar to the patch delivery toolsdescribed herein may be comprised of either plastic or metal and can bedisposable or reusable in a surgical procedure depending on the materialutilized. FIG. 24 is a top view of the patch of FIG. 21 with atwo-pronged pusher tool engaged to a distal edge of the patch. FIG. 25is a side view of the pusher tool shown in use in FIG. 24.

Exemplary Patch Method With Single Suture

FIGS. 28-32 provide an exemplary simplified example of the delivery of asuture guided patch to a surgical site of a suture based repair for atorn rotator cuff.

FIG. 28 illustrates a top down view of a two suture anchor repair of arotator cuff. First, two bone anchors (9A, 9B) are placed in a medialposition on the greater tuberosity. In this simplified example, eachanchor has suture 8 threaded through it. In this simple example, thereis one strand per anchor for total of two strands. Next, both strandsare then passed from underneath the rotator cuff tendon to the top ofthe tendon with a suture passer. These strands form a row about 1.2 cmfrom the cut edge of the tendon.

Next, as shown in FIG. 28 the strands 8A, 8B are then crossed: strand 8Afrom anchor 9A is paired with strand 8B from anchor 9B. After crossing,these 2 strands are brought together outside the body through a cannulawith an 8 mm diameter. Next, outside of the body, these two sutures 8A,8B are threaded through the two continuous suture conduits in a sutureguided patch 50. In this embodiment, the suture patch is loaded with thewidest end (here the distal end) facing towards the body (in a distaldirection towards the surgical site) with the narrow portion (here theproximal portion) directed away from the body or in a proximaldirection. Thereafter, as shown in FIG. 29, the patch 50 is thenadvanced along the two sutures 8A, 8B as the sutures move along thesuture conduits. Patch advancement continues to the point where thedistal end of the patch reaches the place where the sutures 8A, 8Bemerge from the top surface of the rotator cuff tendon.

At this point, as best seen in FIGS. 30 and 31, the patch is sitting onthe top surface of the rotator cuff tendon. Next, the sutures are thenpassed through a free anchor A3 outside the body. The anchor A3 isthreaded along sutures 8A, 8B and is then inserted into the bone on thelateral aspect of the greater tuberosity as shown in FIG. 32. Asappreciated by the location of the anchor A3 in FIG. 32 and the lateraledge of the patch 50 in FIG. 31, in alterative patch embodiments, alonger patch may be selected for any number of possible advantages,depending upon surgeon preference and patient needed. A longer patch maystill have the same medial position but would allow the same patchposition to have the patch pleated or gathered along the sutures therebyadding additional material to the site if needed or to allow more of thesurgical site to be covered such as to permit additional coverage of therotator cuff tendon or to permit anchor A3 to be positioned morelaterally along the lateral aspect of the greater tuberosity. With theillustrative embodiment, the finished construct is shown in the top viewof FIG. 32 as having 2 sutures holding down the medial aspect of therotator cuff at 2 points, holding down the lateral aspect of the rotatorcuff at 1 point and a triangular patch sitting on top of the cuff heldin place using the 2 sutures within the provided suture conduits.

Exemplary Patch Method With Two Tail Suture

FIGS. 33-38 illustrate a two suture anchor delivery of two suture guidedpatches at a surgical site for a suture based repair of a torn rotatorcuff. First, two bone anchors placed in a medial position on the greatertuberosity. In this example, there are two strands per anchor for totalof four strands. FIG. 33 shows the four strands after having been passedfrom underneath the rotator cuff tendon to the top of the tendon with asuture passer. These strands form a row about 1.2 cm from the cut edgeof the tendon. Next, as shown in FIG. 34, the strands are then crossed:1 strand from anchor A is paired with 1 strand from anchor B. Asdescribed above in FIGS. 28-32, after crossing, these 2 strands arebrought together outside the body through a cannula with an 8 mmdiameter. Next, outside of the body, these 2 sutures are threadedthrough two continuous suture conduits in a suture guided patch. In thisembodiment, the suture patch is loaded with the widest end (here thedistal end) facing towards the body (in a distal direction towards thesurgical site) with the narrow portion (here the proximal portion)directed away from the body or in a proximal direction. Thereafter, thepatch is then advanced along the two sutures as the sutures move alongthe suture conduits. Advancement continued to the point where thesutures emerging from the top surface of the rotator cuff tendon. Atthis point, the patch is sitting on the top surface of the rotator cufftendon. Next, the sutures are then passed through the lateral row anchorand secured. The process is repeated for the other two sutures to becrossed, inserted into a patch suture conduit and delivered to thesurgical site and anchored. The suture repair with two suture guidedpatches is shown in FIG. 36. As a result, the finished construct hassutures holding down the medial aspect of the rotator cuff at 2 points,holding down the lateral aspect of the rotator cuff at 2 points withoverlapping triangular patches sitting on top of the cuff each held inplace using the 2 sutures within the provided suture conduits.

FIG. 37 is a top down view of patch cuff repair as in FIG. 36 showing analternative suture guided patch having a segmented suture conduit andthe use of a lateral anchor to secure the narrow or proximal end of thepatch.

FIG. 38 is a top down view at the conclusion of the alternative suturepatch repair of FIG. 37 with two suture guided patches on the rotatorcuff repair. This view also illustrates the suture within the segmentedsuture conduits of both patches as well as the use of the lateral rowanchors instead of adding third anchors as in FIG. 36.

Additional Details of Suture Guided Patches

A suture guided patch is a device used to promote healing at a suturesurgical repair site. A suture guided patch has an overall shape, aproximal end and a distal end. There is at least one suture conduitalong the patch sized to allow passage of a suture and permit relativemovement of the patch along a suture disposed within the suture conduit.In use, when the patch is positioned to promote healing at the surgicalrepair site, a suture disposed within the suture conduit extends alongthe patch beyond the proximal end and beyond the distal end.

Suture guided patches include a general shape or form factor and atleast one suture conduit. The suture conduit is aligned to the patchform factor to produce the desired orientation of the patch in thesurgical site upon delivery using the sutures anchored in the surgicalsite. The dashed lines on each of the exemplary patches in FIGS. 39A-39Dare used to show location and can indicate the position of eithercontinuous or segmented suture conduits. A suture conduit is acontinuous suture conduit if it extends from the proximal end to thedistal end of the patch. In contrast, a suture conduit is a segmentedsuture conduit when two or more suture guide structures are spaced alongthe patch to align the suture disposed within the two or more sutureguide structures. The suture guide structures are provided along thepatch relative to the proximal end and a distal end of the patchdepending on the pathway of the suture relative to the patch such asaligned or divergent.

FIG. 39A is a top view of a suture guided patch having a single sutureconduit and a generally rectangular form factor.

FIG. 39B is a top view of a suture guided patch having two alignedsuture conduits and a generally rectangular form factor. FIG. 39C is atop view of a suture guided patch having two aligned suture conduits anda generally rectangular form factor where the spacing of the sutureconduits is selected to coincide with the spacing of two suture anchors.The exemplary suture guided patches of FIGS. 39B and 39C illustratealigned suture conduits because the suture conduits are about the samespacing at the proximal end of the patch as at the distal end of thepatch.

FIG. 39D is a top view of a triangular shaped suture guided patch havingtwo suture conduits generally aligned with two sides of the triangle.The suture conduits in FIG. 39D are divergent suture conduits becausethe suture conduits are closer at the narrow end of the patch (proximalend) and further apart at the wider end (distal end). Divergent sutureconduits have different spacing at the proximal and distal ends of asuture guided patch.

Construction of various suture patches including multiple layers,stacks, and sandwich structures may be appreciated with reference toFIG. 40A and 40B. FIG. 40A is an exploded view of a suture guided patchhaving an upper layer and a lower layer with several layers of materialbetween the upper and the lower layer. The various layers may includeone or more layers of a non-woven mesh, a woven mesh or a knittedmultifilament mesh. The various structures and arrangements of thecomponents of the patch are made from materials that are bioabsorbable.In some embodiments, the patch is constructed of a biodegradablematerial having a hybrid of a porous material and a material thatprovide strength construct. One exemplary construction of the patch isformed from a PLA or PGA mesh and strips of PLA or PGA are provided forsupport.

FIG. 40B is a perspective view of the layers of FIG. 40A assembled intoa structure suited for use as a suture guided patch. In someembodiments, a suture guided patch comprises two or more layers ofmaterial. The suture guided patch may be configured to deliver a suturedelivered material in a wide variety of constructions. In one aspect, aportion of the patch folded into a plurality of pleats. In someembodiments, when the patch is deployed into the surgical site at leasta portion of the plurality pleats remain. In some suture guided patchembodiments, the patch includes a scaffold sandwiched between outerlayers of a non-woven mesh, a woven mesh or a knitted multifilamentmesh. The one or more layers of the patch are assembled or joined into aunitary structure using a variety of suitable processes for the types ofmaterials used. The materials or layers in a patch may be assembled bystitching the layers together with fibers, bioabsorbable fibers, orsuture, or by joined together by cementing, bonding, embroidering or bythermal processing such as sealing or welding.

In one embodiment, the suture guided patch is configured for designedrelease of a patch delivery material. In one embodiment, at least one ofthe two or more layers of material is selected to carry a patch deliverymaterial. The patch delivery material for a specific suture guided patchis selected to promote a desired interaction including an onset, anincrease, a decrease or a cessation of a related therapeutic,pharmacodynamic, biologic or other effect upon release at the surgicalrepair site. In some configurations, when the patch is in position atthe suture surgical repair site the layer selected to carry a patchdelivery material is directly adjacent to the repair site. In some otherconfigurations, when the patch is in position at the suture surgicalrepair site the layer selected to carry a patch delivery material isseparated from the surgical repair site by another of the two or morelayers of the patch. In various different configurations, a sutureguided patch has an upper layer and a lower layer and a layer betweenthe upper layer and the lower layer, wherein one or more of the upperlayer, the lower layer and the layer between the upper layer and thelower layer is configured to maintain a patch delivery materialaccording to a selected designed time release of the patch deliverymaterial.

The one or more suture conduits of a suture guided patch may be providedin a number of different arrangements depending upon the particularpatch design implemented. A number of different aspects of the variousalternative configurations of a four sided suture guided patch areappreciated with reference to FIGS. 41A-42E. Suture conduits may becontinuous as shown in FIGS. 41A-41D or segmented as in FIGS. 42A-42E.The segmented conduits of FIGS. 42A, 42C and 42D and 42E also illustratea suture conduit extending along an outer surface of the patch.Additionally, one of more suture conduits may be provided on, in orwithin an upper layer as shown in FIGS. 41A, 42A, 42C, 42D and 42E. Inother embodiments, one of more suture conduits may be provided on, in orwithin the lower layer as shown in FIG. 41C and 42B. In otherembodiments, one of more suture conduits may be provided on, in orwithin a layer between the upper layer and the lower layer as shown inFIG. 41B and 41D. In some embodiments, the suture conduit is providedfrom a loop or portion of material used to secure together the variouslayers of material as in FIGS. 42C and 42D. Alternatively, loops ofmaterial or structure may be added to a patch to form suture conduitguides as shown in FIGS. 42A, and 42B.

Additional aspects of suture guided patches may be appreciated byreference to FIGS. 43A-46. FIG. 43A illustrates a top down view of asuture guided patch for use in the process of FIG. 74 to select andprocess a patch before delivery to the surgical site. FIGS. 43B, 43C and43D illustrate top views of different trimming, shaping and foldingoperations on the patch of FIG. 43A. FIG. 43B has rectangular edgesfolded on the left and the right sides of the patch. FIG. 43C has apatch that has been trimmed to have rounded flaps. This patch is alsoshown with a delivery tool—such as the two prong tool describedabove—that may be used to unfold and adjust the position of sized,trimmed or folded patches upon delivery to the surgical site. FIG. 43Dis another variation of a trimmed and folded patch.

FIG. 43E is a perspective view of a folded patch being unfolded at thesurgical site showing how any folded panels or sides are unfolded inorder so that the patch is not damaged.

FIG. 43F is a top down view of deployed patch that had been previouslytrimmed and sized prior to deployment to a surgical site.

Align the same lines as FIG. 43A, FIGS. 44, 45 and 46 illustrate topdown views of patches that may be trimmed, sized or shaped based onsurgeon preference or patient need. Each of these embodimentsillustrates having centrally positioned suture conduits. Otherplacements of the suture conduits along the left or the right sectionsmay be useful for some specific embodiments, anatomical sites or anchorpositions. FIG. 44 is a rectangular patch having aligned sutureconduits. FIG. 44 also shows loading tubes in place within the sutureconduits to quickly load the sutures into the conduits. Additionally,the tubes are shown oversized so that the loading tube can be cut inplace during any timing, shaping or sizing operations. FIG. 45illustrates a similar patch suited for trimming, sizing or shaping. Thisillustrative embodiment includes divergent suture conduits. Divergentconduits are suited to crossed suture delivery as described above. FIG.46 illustrates a hybrid patch design. This patch has a size selected forany desired shaping, sizing or trimming operations. Additionally, thispatch includes both aligned and divergent suture conduits. In use thesuture loading wires may be used to pull the sutures into the desiredsuture conduit orientation. The other unused suture pulls may beremoved.

Exemplary Suture Guided Patch Delivery Tools

FIGS. 47A-67 illustrate the details of the design and use of variousexemplary suture patch delivery tools and devices. A number of differentdelivery tools may be utilized to assist in the delivery of the variousembodiments of the suture guided patch. In one aspect, the sutures areloaded into a continuous suture conduit that is either part of the patchor is provided by a separate loading tube inserted into the patch. Ineither case, the suture remains within the patch after delivery: withinthe suture conduit of one and within the aperture formed by the loadingtool in the other. In either of these examples, a push rod with a distalend adapted to engage a distal portion of the patch may be provided. Oneexample is the two pronged fork described above. Additionally, the endof the push rod may be adapted for engagement with a pocket or receiverin the edge of the patch.

Other delivery tool configurations are also provided to facilitate theadvancement of the patch along the sutures. In addition, as patches aredevised for using in the delivery methods described herein having stowedand deployed configurations, embodiments of the delivery tool provideadditional movement needed to aid some patch embodiments in thetransition to the deployed condition. Some patch embodiments willtransition by virtue of the divergent travel path towards the anchorsand still others will move at least partially upon exiting the reduceddiameter of a working channel of a scope or a delivery tool. The abilityof the patch to transition from stowed to deployed will vary dependingupon a number of factors such as the materials and structures used toconstruct the patch as well as the behavior of the patch once the patchdelivered material is incorporated and prepared for use. A layer may beadded to portions of the patch to permit folding and limit adhesion ofthe patch.

In some embodiments, a suture guided patch is provided in a loadingcartridge. Suture loading elements such as looped lines or rods or maybe inserted into the suture conduits to permit loading the patch ontothe sutures while remaining in the loading cartridge. The cartridge mayhold the patch in a stowed condition or otherwise position the patchwithin the cartridge to receive or incorporate or activate, as needed, apatch delivered material. The cartridge may be a separate component thatis part of a delivery tool, or a separate component. FIG. 47B shows aloading cartridge embodiment coupled to a patch delivery tool. Thecartridge provides one or more loading ports as suited to theintroduction of a patch delivered material. Additionally, the cartridgemay be adapted to hold the patch in a desired orientation or position orcondition to enable loading of biologic materials or other agentsrequiring specific loading techniques.

The various embodiments that follow provide details of exemplarymoveable leg patch delivery tools for delivering one or more sutureguided patches to a surgical site. The step of loading a suture guidedpatch onto a movable leg patch delivery device will vary but eachensures that the patch and the tool may be advanced along the sutures tothe surgical site. As a result, the sutures are loaded into a patchsuture conduit and in position for use with the patch delivery device.Once appropriately loaded, the patch may be advanced along the one ormore sutures towards the surgical site with the assistance of thedelivery tool. After removal of the tool, the sutures remain within oneor more suture conduits of the patch.

Additionally, depending upon the embodiment of the delivery device, themovement of the patch from the stowed condition is produced at least inpart by the separation of the moveable legs. The legs may be biased orprovided with flexible joints for this purpose. Additionally oroptionally, the delivery device legs may include flexible sectionspositioned proximal to the patch loading position that permit the distalportions of the legs to separate as the tool and patch are advancedalong the sutures. The amount of flexibility in the delivery device legsmay be selected based on the amount of movement desired for a patchdeployment or to allow movement in response to the suture pathwaytowards spaced apart anchors. In some embodiments, the delivery tool maybe used for positioning the deployed patch within the surgical repairsite. Once the use of the patch delivery device is completed, the deviceis removed from the surgical site.

In some embodiments the delivery tool may separate upon removal or maybe removed as a single unit. If the delivery tool does not separate onremoval, the delivery tool is removed from the surgical site bywithdrawing it from the surgical site with one or more sutures remainingwithin the one or more suture conduits of the patch. If, the deliverytool does separate for removal, then the user will remove components ofthe delivery tool in sequence from the surgical repair site. At theconclusion of the sequence one or more sutures will be left remainingwithin the one or more suture conduits of the patch. Finally, if apositioning rod is provided or used during the patch deployment process,then the positioning rod is also removed from the surgical site.

The use of the delivery tool may be appreciated with reference to thevarious suture guided patch deployment methods as described in FIGS. 14,16, and 28-38 above. In addition, the use of patch delivery tools may bebetter appreciated with reference to FIG. 73. FIG. 73 is a flow chart ofa method 7300 of an exemplary surgical method using an exemplarymoveable leg patch delivery tool.

FIG. 47A is a top view of a suture patch delivery tool having a handleand an arm projecting from the handle a patch loaded into the distalend. This view also shows the addition of one or more patch deliveredmaterials via a port in the distal end of the tool.

FIG. 47B is a top view of the suture patch delivery tool of FIG. 47Awith a patch within a loading cartridge coupled to the patch deliverytool This view also shows the addition of one or more patch deliveredmaterials via a port in the loading cartridge.

FIG. 48A is a top view of a pincer like mandible or patch release clipsat the end of each of the arms engaged with a suture guided patch. Alsoshown in this view of the stowed patch are three suture loops one at theproximal end and two at the distal end.

FIG. 48B is a top view of the delivery tool and stowed patch of FIG. 48Ashowing looped sutures threaded through each of the suture loops.

FIG. 49 is a top view of the exemplary surgical site of FIG. 29 with thecrossed sutures passed outside the body and ready for loading into thedelivery tool using the looped sutures of FIG. 48B.

FIG. 50 is a top view of the surgical site of FIG. 49 with the crossedsutures passed outside the delivery tool and the delivery tool used toadvance the patch delivery tool and the patch distally towards thesurgical site and just prior to the tool and patch exiting the workingchannel.

FIG. 51 is a top view of the surgical site of FIG. 50 after the patchand delivery tool have been advanced beyond the working channel byoperation of the deploy actuator. Operation of the deploy actuator movedthe patch and the tool along the sutures to position the distal end ofthe patch at the medial anchors as in FIG. 30.

FIG. 52 is a top view of the surgical site of FIG. 51 after operation ofthe release button to open the mandibles or patch clips to separate thepatch from the delivery tool.

FIGS. 53A, 53B and 53C are top views of a moveable biased leg patchdelivery tool with a patch having a cuff or pocket to engage the distalends of the biased legs. FIG. 53A shows the tool and patch advancedalong the sutures and exiting a working channel with the biasing actionof the legs moving the distal end of the patch from a stowed condition.FIG. 53B is a top view of the surgical site of FIG. 53A with the distalportions of the patch and legs of the delivery tool advanced to thesuture anchors. The sutures pass through a loop in the proximal end ofthe patch. FIG. 53C is a top view of the surgical site in FIG. 53B withthe legs of the delivery device withdrawn proximally so as to disengagefrom the pockets or cuffs of the patch.

FIGS. 54A, 54B and 54C are top views of a delivery tool configured toutilize a suture arranged about a portion of an anchor acting as apulley. The pulling suture is wrapped about the anchor and attached to adistal portion of the patch as best seen in FIG. 54A. FIG. 54A alsoshows the tool and patch advanced along the sutures and exiting aworking channel with the patch moving from a stowed condition. FIG. 54Bis a top view of the surgical site of FIG. 54A with the distal portionsof the patch advanced to the suture anchors. FIG. 54C is a top view ofthe surgical site in FIG. 54B with the pull suture separated from theanchor and withdrawn proximally leaving the distal portion of the patchat the medial anchors.

FIGS. 55A and 55B are top down views of an exemplary moveable hollow legpatch delivery tool for delivering a suture guided patch to a surgicalsite. The suture conduit loops of the guided patch are shown loaded onthe distal end of the hollow legs. FIG. 55B illustrates the hollow legdevice and patch in a stowed condition. FIG. 55A illustrates the hollowleg device and patch in a deployed condition.

FIG. 56 is a view of the surgical site similar to that of FIG. 49 withthe crossed sutures outside the body. This view shows the sutures passedcompletely through the hollow legs of the delivery device. The patch onthe distal end of the delivery device is shown in a deployed condition.

FIG. 57 is a view of the surgical site of FIG. 56 the hollow legs of thedelivery device moved together and placing the patch in a stowedcondition. Optionally, the patch may be loaded onto the delivery devicestowed and then the sutures passed through the hollow legs as shown inFIG. 56. This view also show the stowed patch and closed legs of thedelivery device prior to introducing the loaded delivery device into aworking channel for delivery to the surgical site.

FIG. 58 is a view of the surgical site of FIG. 57 after the deliverydevice and the patch have been advanced through and exited the workingchannel of a scope or cannula and moved into a deployed condition. Thedistal end of the patch is also shown in an position approaching theanchors.

FIG. 59 is a view of the surgical site of FIG. 58 illustrating one legof the delivery device moving to adjust a portion of the patch relativeto the anchor or the surgical site.

FIG. 60 is a view of the surgical site of FIG. 58. This view also showsan embodiment of the delivery tool where the tool separates for removalfrom the surgical site after delivery of the patch. The left leg of thetool is shown withdrawn from the body with the right leg in place at thesurgical site. An optional tool is shown in this view that is used tohold the patch in the deployed position relative to the anchors or thesurgical site while the device is withdrawn or to adjust the patch aftertool withdrawal. This view shows the optional tool provided via anothersurgical access but the tool may be provided along with the deliverydevice in other configurations.

FIG. 61 is a top down view of the surgical sites of FIG. 58 afterremoval of the delivery tool and securing the patch in the surgicalsite.

FIGS. 62 and 63 are side and top down views respectively of a hollow legloaded onto the suture guides of a patch. The distal most end of thehollow leg is reduced to produce a shoulder to engage one of the sutureloops to aid movement of the patch along the sutures. These views alsoshow a distal most suture guide loop that is sized to the reducedportion of the hollow leg while additional suture guide loops are sizedto the outer dimension of the proximal hollow leg. The patch isillustrated with one reduced size suture loop in the reduced area.Additional suture loops may be provided along the reduced area towardsthe distal end.

FIG. 64 is a side view of a patch loaded onto a reduced distal endhollow leg as in FIG. 62. This view also illustrates a different lengthof setback from the distal end of the patch to the shoulder. The upperportion of the reduced area is also provided with a shaped tip to permituse of the hollow leg as a positioning tool after or during patchdelivery.

FIGS. 65A and 65B are perspective views of two hollow leg delivery toolembodiments configured to have the legs separate after patch deliveryand for withdrawal from the surgical space. A sleeve positioned aroundthe proximal portion of the legs to maintain the legs in position duringdelivery is shown in each view. FIG. 65A illustrates the sleeve having aperforated segment between each of the proximal portions of the tool.FIG. 65B illustrates a rip cord provided in the sleeve being pulled toseparate the legs for removal.

FIG. 66 is a top down view of a hollow leg delivery device that includesa positioning tool or rod. This view shows the delivery tool and patchin a deployed condition with the positioning tool coupled to a distalportion of the patch.

FIG. 67 is a top down view of a hollow leg delivery device that includesa positioning tool or rod adapted to engage with a pocket or cuffprovided on the patch as shown in FIGS. 53A-53C. This view shows thedelivery tool and patch in a stowed condition with the positioning toolwithin the pocket or cuff of the patch.

In still another aspect, the hollow leg delivery device 200 may beadapted for use as a measuring device useful in estimating the sizes andspacing of relevant portions of the suture based surgical repair site.These measurements or sizing estimates may then be used in the selectionof a patch from a selection of pre-set patches of different dimensions.Additionally or optionally the measurement and estimation tools mayprovide input for use in one or more patch selecting and preparingmethods 7400 in FIG. 74 or one of FIGS. 43A to 50. In one aspect, thepatch measurement and estimating device is adapted to measure thedistance between the two medial anchors and the distance between themedial row anchors and lateral row anchors. In one embodiment, a leg ofthe delivery device or other suitable tube is adapted to receive asuture from the surgical site. The tube or leg would then slide down thesuture to the anchor. In one embodiment, the suture is a suture from themedial row. The tube should have circular windows spaced at differentlengths. Exemplary spacing for the windows includes 0.5, 1.0, 1.5 and2.0 cm. The tube would include two windows at each length on oppositesides of the tube. In another embodiment, a measuring device to measurethe distance between the 2 medial anchors would be 2 hollow leg flexibletubes such as the legs of the device 200. The legs are joined togetheras described herein. A string or filament or suture of known length isattached to the distal most end of each of the legs. The string orfilament is attached so as to limit the maximum amount that the distalends of the legs are separated. Then, sutures from the medial anchors tobe used for suture guided patch delivery would be passed though thehollow leg conduits. The bendable leg measurement device is thanadvanced along the suture as would be done during delivery of a patch.Advancement of the hollow legs of the measurement device continuesthrough the cannula until the distal ends touch the medial anchors. Atthis point, the distal end of the hollow legs is at the maximum width.The string or filament length may be set to the maximum width for apatch in the deployed configuration. In this way a potential patch sizemay be tested with the string size prior to loading onto the sutures. Ifthe test string was set at 2.0 cm for example, then when in place at themedial anchors, so long as the string was not too taught, then one canconfirm that a patch sized for deployment to a 2.0 cm delivery spacingwould fit between the 2 medial anchors. Other sizes may be used or themeasurement tools may be configured for use with the patch sizesincluded in a pre-set size patch kit.

Exemplary Surgical Methods Incorporating Suture Guided Patches

FIGS. 68-74 provide additional details of surgical methods where one ormore steps of a suture repair workflow is modified to incorporate one ormore of the various embodiments of suture guided patches describedherein.

FIG. 68 is a flow chart of an exemplary surgical method for placing asuture guided patch in a surgical site (method 6800). Method 6800 beginsat step 6805 by placing one or more suture anchors of the surgical site.Next, at step 6810, performing one or more steps of a suture repairprocedure is needed before placement of a suture guided patch at thesurgical site. Next, at step 6815, inserting a suture used in the suturerepair procedure through a suture conduit of the suture guided patch.Thereafter, there is the step of advancing the patch along the suture(step 6820). Next, at step 6825, is the step of securing the patch inthe surgical site with the suture. Finally, there is the step ofreleasing from the patch at least one patch delivered material. (step6830).

FIG. 69 is a flow chart of an exemplary surgical method 6900 for placing2 or more suture guided patches in a surgical site. First, at step 6905,there is the step of placing one or more suture anchors at the surgicalsite. Next, at step 6910, there is the step of performing one or moresteps of the suture repair procedure as needed before placement of asuture guided patch at the surgical site. Thereafter, there is a step ofinserting a suture used in the suture repair procedure through a sutureconduit of the suture guided patch (Step 6915) and then advancing thepatch along the suture (step 6920). At this point, the surgeon maychoose to secure the patch in the surgical site (step 6925 YES) or waitto secure all or another patch so that all patches are securedsimultaneously after being delivered. If the surgeon determines thatadditional patches are to be delivered by answering yes step 6930 thenthe process repeats at step 6915 by inserting another suture guidedpatch or delivery to the surgical site. After all patches are delivered,the patches may be secured together (as shown in FIGS. 18, 19, 36 and38) or using other suitable techniques (step 6935). Finally, there isthe step of releasing from the patch at least one patch deliveredmaterial. (step 6940).

FIG. 70 is a flow chart of an exemplary surgical method for placing asuture guided patch in a surgical site including the use of a patch forthe delivery of a modified augmentation device or a modifiedinterposition device. A modified augmentation device or a modifiedinterposition device may be coupled in an appropriate manner to a sutureguided patch adapted for the purpose such as by using the techniquesdescribed above with regard to FIGS. 43A-46. Thereafter, at step 7005,there is the step of placing one or more suture anchors at the surgicalsite. Next, at step 7010, there is the step of performing one or moresteps of the suture repair procedure as needed before placement of asuture guided patch at the surgical site. Thereafter, there is a step ofinserting a suture used in the suture repair procedure through a sutureconduit of the suture guided patch (Step 7015) and then advancing thepatch along the suture to the surgical site (step 7020). When anembodiment of the suture guided patch is used to provide an augmentationor interposition device (step 7025 is yes) then both the augmenteddevice and the patch are secured as appropriate to the surgical site(7030). Finally, there is the step of releasing from the patch at leastone patch delivered material. (step 7035) which may have a speciallydevised material release profile for use in conjunction with themodified device.

FIG. 71 is a flow chart of an exemplary surgical method 7100 of themovement from a stowed condition of a suture guided patch beingdelivered to a surgical site. At step 7105 there is the step of securingat least 2 suture anchors in a surgical site. Next, at step 7110 thereis the step of performing one or more steps of the suture repairprocedure as needed before placement of the suture guided patch at thesurgical site. Next, at step 7115, there is the step of inserting onesuture from the 1^(st) suture anchor into a 1^(st) suture conduit of thepatch and one suture from a 2^(nd) suture anchor into a 2^(nd) sutureconduit of the patch. Thereafter, at step 7120, there's the step ofadvancing the patch and stowed configuration along the 1^(st) and 2^(nd)sutures towards the surgical site. Next, at step 7125, is the step ofmoving the patch from the stowed configuration as the patch movestowards the surgical site. Is to be appreciated that the step may beaccomplished in a number of different ways. One way the patch moves fromthe step configuration is simply by having the patch loaded incompression within the working channel of the instrument used to deliverthe patch. As the patch moves out of the working channel, the patchmoves from the stowed configuration. In another example, the patch maybe urge to move as it advances along the suture conduits because thesuture conduits are oriented in a diverging path whereby as the sutureconduits move towards the suture anchors the patch will be moved alongwith the conduits into a deployed configuration. Thereafter, at step7130, is the step of securing the patch in the surgical site with the1^(st) suture and the 2^(nd) suture. Here as with the other methods thesuture used to deliver the patch and that remains within the sutureconduits of the patch is used to secure the patch at the surgical site.Next, at step 7135, depending upon the specific design release profileof the patch, there's the step of releasing from the patch at least onepatch delivered material.

FIG. 72 is a flow chart of an exemplary surgical method 7200 for the useof an exemplary patch delivery tool for delivering a suture guided patchto a surgical site. At step 7205 there is the step of securing at least2 suture anchors in a surgical site. Next, at step 7210 there is thestep of performing one or more steps of the suture repair procedure asneeded before placement of the suture guided patch at the surgical site.Next, at step 7215, is the step of loading a suture guided patch onto adelivery tool. Next, at step 7220, is the step of engaging the one ormore sutures with the delivery tool or the patch to allow advancement ofthe patch along the one or more sutures. Next, at step 7225, is the stepof inserting a suture used in the suture repair procedure through asuture conduit of the suture guided patch. Next, at step 7230, is thestep of advancing the patch along the one or more sutures using thedelivery tool. Next, at step 7235, is the step of positioning the patchwithin the surgical repair site. Next, at step 7240, is the step ofremoving the delivery tool from the surgical repair site leaving the oneor more sutures within the one or more suture conduits of the patch.Next, at step 7245, securing the patch in the surgical site with the oneor more sutures. Next, releasing from the patch at least one patchdelivered material (step 7250).

Further to the exemplary delivery method 7200 in FIG. 72 and withreference to FIG. 58, as the suture delivered device and hollow legdelivery tool advance along the sutures and through the deliverycannula, the hollow legs of the device will separate as the individualsutures lead to each of the individual suture anchors 9A,9B. The actionof the legs of the hollow leg delivery device to open will alsotransition the patch from the stowed condition into a deliveredcondition. In the delivered condition, at least one side of the patchcorresponds to the spacing between adjacent suture anchors. Thereafter,the hollow leg delivery tool is withdrawn leaving the suture deliveredpatch in place. Next, the completion of the suture repair procedure iscompleted by anchoring the sutures that are along the patch to theappropriate location within the surgical field. As a result of theanchoring of the sutures, the suture delivered patch is also secured inplace. The process is repeated for additional suture anchors and patchesdepending upon the desired surgical outcome. While described withspecific mention of the hollow leg delivery device embodiments, theflexible legs and suture following movement of the delivery device andthe patch occurs as well in the embodiments and illustrative patchdelivery in FIGS. 51 & 53A-53C.

FIG. 73 is a flow chart of an exemplary surgical method 7300 for the useof an exemplary moveable leg patch delivery tool for delivering a sutureguided patch to a surgical site. As with the prior methods, one or moresutures anchors are placed (step 7305) and one or more steps of theprocedure are performed as necessary (step 7310). Next, at step 7315,there is a step of loading a suture guided patch onto a movable legpatch delivery device. Next, at step 7320, is the step of engaging twosutures with the patch or the patch delivery device to allow advancementof the patch along the one or more sutures towards the surgical site.Next, at step 7325, is the step of advancing the patch in the stowedcondition along the 2 sutures towards the surgical site using the patchdelivery device. Next, at step 7330, is the step of moving the patchfrom the stowed condition by separating the legs of the patch deliverydevice. Next, at step 7335, is the step of positioning the deployedpatch within the surgical repair site. Next, is the step of removing thedelivery tool from the surgical repair site, step 7340. In someembodiments the delivery tool may separate upon removal or may beremoved as a single unit. This decision point is reflected at step 7345.If the delivery tool does not separate on removal, the answer at step7345 is no and the method continues at step 7350. The delivery tool isremoved from the surgical site with the one or more sutures remainingwithin the one or more suture conduits of the patch. If, the deliverytool does separate for removal, step 7345 is yes, then the methodproceeds at step 7355. In the step the user will remove components ofthe delivery tool in sequence from the surgical repair site. At theconclusion of the sequence one or more sutures will be left remainingwithin the one or more suture conduits of the patch. Next at step 7360,the positioning rod if used during the use of the delivery device or ifprovided with the delivery device is also removed from the surgicalsite. (see FIGS. 24, 66 and 67). Next, at step 7365, if not securedpreviously, the patch is secured in the surgical site with the one ormore sutures that remain within suture conduits of the patch.Thereafter, while remaining at the surgical site according to thedesigned release profile, there's the step of releasing from the patchat least one patch delivered material. (Step 7370).

FIG. 74 is a flow chart of an exemplary surgical method for selectingand optionally preparing a selected patch for suture guided delivery toa surgical site. In order to provide additional flexibility for the useof suture delivered patches, a number of different patch types and sizesmay be provided to the surgeon or adaption to a particular surgical caseor patient need. As with the prior methods, method begins by placing oneor more suture anchors at a surgical site. (Step 7405). Next, one ormore steps of a suture repair procedure are performed as needed beforethe placement of the suture guided patch at the surgical site. (Step7410). Next, the surgeon selects one or more suture guided patches foruse in the suture-based surgical repair. (Step 7415). The process ofselecting includes the surgeon evaluation of our number of differentfactors of a particular suture guided patch. Among the exemplarycharacteristics upon which to make this selection are suture conduitsspacing (step 7420), suture conduit orientation (step 7425), number ofsuture conduits (step 7430), patch size and shape (step 7435), anddesigned release of patch material (step 7440). Next, as a result of theselection process above, is the step of preparing the selected patch forsite-specific delivery (step 7445). Here, the patch may be optionallyadapted for the particular surgery or repair being performed. By way ofexample, a selected patch may be trimmed (step 7450), shaped (step 7455)or folded one or more times (step 7460). In one embodiment, the sutureguided patches may come in a standard width, such as 1.0 cm, 1.5 cm or2.0 cm or more than the width between adjacent suture anchors but besupplied in a standard length, such as a length sufficient for mostsurgical applications, for example 10 cm or less depending upon surgicalneed and surgeon preference. As part of step 7450, the patch would thenbe cut to the desired length once the desired preset with was selected.Additionally, with regard to the shaping step 7455, patches of differentshapes may be provided with a different area of coverage whereby afterselecting the particular shape of patch for use it may then be trimmedaccording to step 7450 or folded according to 7460 in order to that theparticular need of a surgical site repair. (See FIGS. 43A-46 above). Inthis way, a suture guided patch may be trimmed or shaped to sizestarting from a standard shaped areas (all in square centimeters) of1.0, 1.5, 2.0, 2.5, 3.0, 3.5, 4.0 or others depending on surgical needs.Thereafter, at step 7465, the selected and prepared patch is loaded ontoone or more sutures and/or a delivery tool, as desired. Next, at step7470 the patch is advanced along the one or more sutures towards thesurgical site. Afterwards, the patch is secured in the surgical site orsufficiently secured or any additional patches or steps to be taken atthe surgical site for securing this patch. (Step 7475). Next, at step7480, the method then proceeds or the additional selection preparationloading and delivery of any additional patches according to the surgicalplan. If more patches are to be delivered the process continues byreturning to the selecting step 7415. If all patches have been deliveredaccording to the surgical plan, then the answer at step 7480 is nosurgery is completed and according to the designed release profile ofthe patch, at least one patch lived material will be released from thepatch (step 7485).

While the above embodiments have described primarily for use with therepair of the rotator cuff of the shoulder, it is to be appreciated thatthe surgical repair patches, tools and suture anchor delivery methodsdescribed herein may be adapted to a wide variety of soft tissue repairof ligaments and joints such as, for example:

Shoulder

Capsular stabilization

Bankart repair

Anterior shoulder instability

SLAP lesion repairs

Capsular shift or capsulolabral reconstructions

Acromioclavicular separation repairs

Deltoid repairs

Biceps tenodesis

Foot and Ankle

Hallux valgus repairs

Medial or lateral instability repairs/reconstructions

Achilles tendon repairs/reconstructions

Mid and forefoot reconstructions

Metatarsal ligament/tendon repairs/reconstructions

Bunionectomy

Elbow

Ulnar or radial collateral ligament reconstruction

Lateral epicondylitis repair

Biceps tendon repair

Hand and Wrist

Collateral ligament repair

Scapholunate ligament reconstruction

Volar plate reconstruction

Tendon transfers in phalanx

Hip

Acetabular labral repair

Knee

Extra-capsular repairs

Medial collateral ligament

Lateral collateral ligament

Posterior oblique ligament

Patellar realignment and tendon repairs

Illiotibial band tenodesis

VMO advancement

Joint capsule closure

In still other embodiments, various augmentation devices andinterposition devices may also be modified for use with the sutureguided techniques described herein.

“Augmentation device (or graft)” as used herein refers to a materialthat can be used to strengthen a rotator cuff repair. For example, asurgeon may enhance the strength of a rotator cuff repair made withsutures by incorporating a reinforcing material into the repair. In oneaspect, and augmentation device is modified according to the principlesdescribed herein to permit suture guided delivery of the modifiedaugmentation device. The modified augmentation device may include adedicated suture channel, a continuous suture channel, and intermittentsuture channel or joined to an embodiment of a suture guided patchwhereby the suture guided patch provides for suture guided delivery ofthe modified augmentation device.

“Interposition device (or graft)” as used herein refers to a materialthat is used to bridge a gap (or defect) between the end of a tendon andits bony insertion site. In one aspect, and interposition device ismodified according to the principles described herein to permit sutureguided delivery of the modified interposition device. The modifiedinterposition device may include a dedicated suture channel, acontinuous suture channel, and intermittent suture channel or joined toan embodiment of a suture guided patch whereby the suture guided patchprovides for suture guided delivery of the modified interpositiondevice.

Augmentation and interposition devices, modified for advantageoussuture-based delivery techniques described herein may, in certainembodiments, be formed as comprising PHAs, and more specificallypoly-4-hydroxybutyrate and copolymers thereof, which are absorbable, andto methods for making and delivering such devices for the repair ofrotator cuff tears and other tendon or ligament repairs, have beendeveloped. In one embodiment, the devices comprise PHA fibers thatprovide high initial strength and prolonged strength retention whenimplanted in vivo, and may incorporate other PHA components, such as PHAnon-woven textiles, or other materials that are biocompatible. Thesedevices should be at least partly porous, ideally with pore sizes of atleast 10 microns, and be suitable to encourage tissue in-growth.

The modified augmentation and interposition devices should degrade overtime following implantation, and improve the long-term outcome ofrotator cuff repair. Preferably the devices degrade to non-inflammatorymetabolites that are already present in the body. The devices may bereplaced by new tissue as they are remodeled in vivo. During the earlystages of the remodeling process it is desirable for the devices toretain sufficient strength to provide an effective repair. Whiledesiring not to be bound by theory, it is believed that the augmentationand interposition devices may permit a patient to undergo moreaggressive rehabilitation than would have been possible without the useof the devices, for example, when compared to a primary suture repairalone.

The various embodiments of the modified augmentation and interpositiondevices have many common characteristics, those of ordinary skill willappreciate that the size and shape of the devices will be dependent uponthe particular tendon or ligament being repaired, the type of surgicalprocedure used, size of the defect to be repaired, or of the repair tobe augmented. The modified augmentation and interposition devices may beapproximately the same size as the defect, but may also be larger orsmaller. Alternatively, the augmentation and interposition device may becut, trimmed or tailored by the surgeon to fit the defect in such a wayas to not comprise the functionality of the device.

As a result, in one advantageous aspect, the suture patches describedherein are configured to be incorporated directly and effortlessly intothe surgical workflow that already includes the use of anchored suturesfor suture repair. The surgical and patch delivery methods describedabove in FIGS. 68-74 may also be modified to include additional oroptional steps from other described methods or conventional surgicaltechniques appropriate to suture-based surgical repairs. For example,the suturing construct with splice tails as illustrated and described inU.S. Pat. No. 8,834,521 FIGS. 1A-1D and FIGS. 7-12 can be modified asdescribed herein to add one or more embodiments of a suture guidedpatch. In yet another variation, the various double row constructtechniques described in US Patent Publication 2010/0249834 FIGS. 2-4 canbe modified as described herein to add one or more embodiments of asuture guided patch. In still additional aspects, the various sutureguided patches and techniques described herein may also be incorporatedinto the surgical workflow that includes other fasteners or retainerssuch as described in U.S. Patent Application Publication 2003/0130694.By way of example and not limitation, the use of additional patches ofdifferent size or shape, methods and sequence for securing patches,selection an order of the delivery of patches depending upon the desiredtype, ratio or amount of a designed release of patch delivered materialsand other variations depending upon a number of factors includingpatient specific needs surgical protocols, indications for use insurgeon preference.

Additionally or optionally, through the use of the modified augmentationand interposition devices described above, suture-based surgicalworkflows may now incorporate suture guide patches alone or incombination with one or both of the modified augmentation devices orinterposition devices described above.

As is appreciated by the details provided herein, the various patchembodiments can be manufactured to permit delivery into the jointthrough small diameter cannulas utilizing an embodiment of the deliverytool described herein while observing through an arthroscope. In thesecases, the patches must be flexible, and of a size and shape thatpermits them to be deployed through a cannula. Prior to delivery, thepatches may be compressed, folded, stretched or otherwise placed undertension and stowed appropriately on a suture guided delivery tool. Ifdesired, the suture guided delivery tool may comprise shape memorymaterials that cause the tool to open or expand after passing throughthe cannula while traversing along the suture. For example, in anembodiment of the hollow leg delivery tool, the hollow legs may compriseshape memory joints that cause the legs of the device devices to springopen upon after passage through the cannula. These memory materials maybe made from a PHA material, another absorbable material, or from apermanent material such as nitinol.

Additionally or alternatively, additional various details for strengthor reinforcing materials, porous materials, compositions, construction,patch delivered materials are provided in: U.S. Pat. Nos. 8,016,883;8,361,113, 6,080,192; 7,082,337; 7,357, 810; 8,876,864; 8,231,653,8,277,458, 6,514,274, United States Patent Application Publication US2007/0123984; United States Patent Application Publication 2008/0027470;United States Patent Application Publication 2013/0066370; United StatesPatent Application Publication 2014/0277449; United States PatentApplication Publication 2011/0091515, United States Patent ApplicationPublication 2012/0265219, each of which is incorporated herein byreference in its entirety.

Additionally or alternatively a patch or layer or overall design orconstruction of a patch may include aspects of the scaffold and otherdetails of the use of one or more of or a plurality of directionallyoriented bioresobable polymer films according to the various embodimentsdescribed in U.S. Pat. No. 8,226,715. In one aspect directionalorientation is aligned with the axis of the suture, a major axis of thepatch, a minor axis of the patch or at an angle with respect to one ofthe above.

When a feature or element is herein referred to as being “on” anotherfeature or element, it can be directly on the other feature or elementor intervening features and/or elements may also be present. Incontrast, when a feature or element is referred to as being “directlyon” another feature or element, there are no intervening features orelements present. It will also be understood that, when a feature orelement is referred to as being “connected”, “attached” or “coupled” toanother feature or element, it can be directly connected, attached orcoupled to the other feature or element or intervening features orelements may be present. In contrast, when a feature or element isreferred to as being “directly connected”, “directly attached” or“directly coupled” to another feature or element, there are nointervening features or elements present. Although described or shownwith respect to one embodiment, the features and elements so describedor shown can apply to other embodiments. It will also be appreciated bythose of skill in the art that references to a structure or feature thatis disposed “adjacent” another feature may have portions that overlap orunderlie the adjacent feature.

Terminology used herein is for the purpose of describing particularembodiments only and is not intended to be limiting of the invention.For example, as used herein, the singular forms “a”, “an” and “the” areintended to include the plural forms as well, unless the context clearlyindicates otherwise. It will be further understood that the terms“comprises” and/or “comprising,” when used in this specification,specify the presence of stated features, steps, operations, elements,and/or components, but do not preclude the presence or addition of oneor more other features, steps, operations, elements, components, and/orgroups thereof. As used herein, the term “and/or” includes any and allcombinations of one or more of the associated listed items and may beabbreviated as “/”.

Spatially relative terms, such as “under”, “below”, “lower”, “over”,“upper” and the like, may be used herein for ease of description todescribe one element or feature's relationship to another element(s) orfeature(s) as illustrated in the figures. It will be understood that thespatially relative terms are intended to encompass differentorientations of the device in use or operation in addition to theorientation depicted in the figures. For example, if a device in thefigures is inverted, elements described as “under” or “beneath” otherelements or features would then be oriented “over” the other elements orfeatures. Thus, the exemplary term “under” can encompass both anorientation of over and under. The device may be otherwise oriented(rotated 90 degrees or at other orientations) and the spatially relativedescriptors used herein interpreted accordingly. Similarly, the terms“upwardly”, “downwardly”, “vertical”, “horizontal” and the like are usedherein for the purpose of explanation only unless specifically indicatedotherwise.

Although the terms “first” and “second” may be used herein to describevarious features/elements (including steps), these features/elementsshould not be limited by these terms, unless the context indicatesotherwise. These terms may be used to distinguish one feature/elementfrom another feature/element. Thus, a first feature/element discussedbelow could be termed a second feature/element, and similarly, a secondfeature/element discussed below could be termed a first feature/elementwithout departing from the teachings of the present invention.

Throughout this specification and the claims which follow, unless thecontext requires otherwise, the word “comprise”, and variations such as“comprises” and “comprising” means various components can be co-jointlyemployed in the methods and articles (e.g., compositions and apparatusesincluding device and methods). For example, the term “comprising” willbe understood to imply the inclusion of any stated elements or steps butnot the exclusion of any other elements or steps.

As used herein in the specification and claims, including as used in theexamples and unless otherwise expressly specified, all numbers may beread as if prefaced by the word “about” or “approximately,” even if theterm does not expressly appear. The phrase “about” or “approximately”may be used when describing magnitude and/or position to indicate thatthe value and/or position described is within a reasonable expectedrange of values and/or positions. For example, a numeric value may havea value that is +/− 0.1% of the stated value (or range of values), +/−1% of the stated value (or range of values), +/− 2% of the stated value(or range of values), +/− 5% of the stated value (or range of values),+/− 10% of the stated value (or range of values), etc. Any numericalvalues given herein should also be understood to include about orapproximately that value, unless the context indicates otherwise. Forexample, if the value “10” is disclosed, then “about 10” is alsodisclosed. Any numerical range recited herein is intended to include allsub-ranges subsumed therein. It is also understood that when a value isdisclosed that “less than or equal to” the value, “greater than or equalto the value” and possible ranges between values are also disclosed, asappropriately understood by the skilled artisan. For example, if thevalue “X” is disclosed the “less than or equal to X” as well as “greaterthan or equal to X” (e.g., where X is a numerical value) is alsodisclosed. It is also understood that the throughout the application,data is provided in a number of different formats, and that this data,represents endpoints and starting points, and ranges for any combinationof the data points. For example, if a particular data point “10” and aparticular data point “15” are disclosed, it is understood that greaterthan, greater than or equal to, less than, less than or equal to, andequal to 10 and 15 are considered disclosed as well as between 10 and15. It is also understood that each unit between two particular unitsare also disclosed. For example, if 10 and 15 are disclosed, then 11,12, 13, and 14 are also disclosed.

Although various illustrative embodiments are described above, any of anumber of changes may be made to various embodiments without departingfrom the scope of the invention as described by the claims. For example,the order in which various described method steps are performed mayoften be changed in alternative embodiments, and in other alternativeembodiments one or more method steps may be skipped altogether. Optionalfeatures of various device and system embodiments may be included insome embodiments and not in others. Therefore, the foregoing descriptionis provided primarily for exemplary purposes and should not beinterpreted to limit the scope of the invention as it is set forth inthe claims.

The examples and illustrations included herein show, by way ofillustration and not of limitation, specific embodiments in which thesubject matter may be practiced. As mentioned, other embodiments may beutilized and derived there from, such that structural and logicalsubstitutions and changes may be made without departing from the scopeof this disclosure. Such embodiments of the inventive subject matter maybe referred to herein individually or collectively by the term“invention” merely for convenience and without intending to voluntarilylimit the scope of this application to any single invention or inventiveconcept, if more than one is, in fact, disclosed. Thus, althoughspecific embodiments have been illustrated and described herein, anyarrangement calculated to achieve the same purpose may be substitutedfor the specific embodiments shown. This disclosure is intended to coverany and all adaptations or variations of various embodiments.Combinations of the above embodiments, and other embodiments notspecifically described herein, will be apparent to those of skill in theart upon reviewing the above description.

What is claimed is:
 1. A method of delivering a suture guided patch to asurgical site of a suture repair procedure, comprising: placing one ormore suture anchors at the surgical site; pressing or screwing one ofthe one or more suture anchors into a bone, a tendon, a ligament, or amuscle at the surgical site; inserting a suture secured to one of theone or more suture anchors through a suture conduit of the suture guidedpatch; advancing the patch along the suture in the suture conduit; andsecuring the patch in the surgical site using the suture in the sutureconduit.
 2. The method of claim 1 further comprising: performing one ormore steps of the suture repair procedure before the inserting suturestep.
 3. The method of claim 1 further comprising: delivering anothersuture guided patch by repeating the inserting step and the advancingstep.
 4. The method of claim 1 wherein after performing the steps thereis a suture in a first suture conduit of a first patch and a secondsuture in a second suture conduit of a second patch.
 5. The method ofclaim 4 wherein after the securing step the first patch is adjacent tothe second patch.
 6. The method of claim 4 wherein after the securingstep a distal end of the first patch is adjacent to a distal end of thesecond patch.
 7. The method of claim 4 wherein after the securing stepthe first patch is separated from the second patch by a portion of thebone, the tendon, the ligament, or the muscle at the surgical site. 8.The method of claim 1 further comprising: maintaining the patch in astowed configuration during at least a portion of the advancing step. 9.The method of claim 8 wherein the step of transitioning the patch out ofthe stowed configuration occurs after the patch exits a working channelof a surgical instrument used at the surgical site.
 10. The method ofclaim 9 wherein the surgical instrument is one of an endoscope, anarthroscope, or a trocar.
 11. The method of claim 1 wherein the suturerepair procedure is a rotator cuff repair procedure.
 12. A method ofdelivering a first suture guided patch and a second suture guided patchto a surgical site for a suture repair procedure, comprising: securing afirst suture anchor to a first anatomical location at the surgical site;securing a second suture anchor to a second anatomical location at thesurgical site; inserting a first suture secured to the first sutureanchor through a suture conduit of the first suture guided patch;advancing the first suture guided patch along the first suture in thesuture conduit; inserting a second suture secured to the second sutureanchor through a suture conduit of the second suture guided patch; andadvancing the second suture guided patch along the second suture in thesuture conduit.
 13. The method of claim 12 further comprising:positioning a distal most end of the first suture guided patch adjacentto the first suture anchor and positioning a distal most end of thesecond suture guided patch adjacent to the second suture anchor.
 14. Themethod of claim 12 further comprising securing the first suture guidedpatch in the surgical site using the first suture and securing thesecond suture guided patch in the surgical site using the second suture.15. The method of claim 13 further comprising: advancing a third sutureguided patch along a suture secured to the first suture anchor or alonga suture secured to the second suture anchor until a distal most end ofthe third suture guided patch is adjacent to the distal end of the firstsuture guided patch or the distal end of the second suture guided patch.16. The method of claim 15 further comprising securing the third sutureguided patch in the surgical site using the suture within the thirdsuture guided patch.
 17. The method of claim 12 wherein the firstanatomical location at the surgical site or the second anatomicallocation at the surgical site is one of a bone, a tendon, a ligament, ora muscle at the surgical site.
 18. The method of claim 12 wherein afterperforming the step of securing the first suture anchor to the firstanatomical location at the surgical site and the step of securing thesecond suture anchor to the second anatomical location at the surgicalsite the spacing between the first suture anchor and the second sutureanchor is between 0.8 cm and 1.5 cm.
 19. The method of claim 12 furthercomprising trimming the first suture guided patch before or after theinserting the first suture through the suture conduit of the firstsuture guided patch or trimming the second suture guided patch before orafter the inserting the second suture through the suture conduit of thesecond suture guided patch.
 20. The method of claim 12 furthercomprising: loading, providing, incorporating, or encapsulating into thefirst suture guided patch or the second suture guided patch at least onepatch delivered material.
 21. The method of claim 20 wherein the patchdelivered material is any of a therapeutic agent, a diagnostic agent, ora prophylactic agent maintained within a layer of the patch, a portionof a layer of the patch or within the patch as a liquid, a powder, agel, a foam, a particulate media, a solid, a suspended solids, anengineered particle or a nanoparticle.
 22. The method of claim 12further comprising selecting for use at the surgical site for the suturerepair procedure first suture guided patch or the second suture guidedpatch that contains an autograft material, an allograft material, or axenograft material.
 23. The method of claim 12 wherein the surgical sitecomprises a shoulder, a foot, an ankle, an elbow, a hand, a wrist, ahip, or a knee.
 24. A method of delivering a suture guided patch to asurgical site for a suture repair procedure, comprising: securing asuture anchor of a first row of suture anchors at the surgical site;inserting a suture secured to the suture anchor of the first row ofsuture anchors through a suture conduit of the suture guided patch;advancing the suture guided patch along the suture in the suture conduittowards the first row of suture anchors; and maintaining the position ofthe suture guided patch at the surgical site by securing the suture to asuture anchor of a second row of suture anchors.
 25. The method of claim24 further comprising: securing an another suture anchor of the firstrow of suture anchors at the surgical site; inserting a suture securedto the another suture anchor of the first row of suture anchors througha suture conduit of an another suture guided patch; advancing theanother suture guided patch along the suture in the suture conduittowards the first row of suture anchors; and maintaining the position ofthe another suture guided patch at the surgical site by securing thesuture to an another suture anchor of the second row of suture anchors.26. The method of claim 24 wherein the surgical site is one of a bone, atendon, a ligament, or a muscle at the surgical site.
 27. The method ofclaim 24 wherein the spacing between the first row of suture anchors andthe second row of suture anchors is between 0.8 cm and 1.5 cm.
 28. Themethod of claim 25 further comprising: loading or incorporating at leastone patch delivered material into the suture guided patch or the anothersuture guided patch.
 29. The method of claim 28 further comprising:stimulating tissue in-growth at the surgical site with the at least onepatch delivered material or stimulating tissue regeneration at thesurgical site with the at least one patch delivered material.
 30. Themethod of claim 24 wherein the surgical site comprises a joint.